Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for intraoral - periapical first radiographic image D0220. We decided 
that the Plan does not have to pay for retainer crown - porcelain/ceramic (D6740), pontic - porcelain fused to 
high noble metal (D6240), and pontic - porcelain fused to noble metal (D6242). 
 
You asked the Plan to pay for the dental services. You say that you chose these dental specialists because they 
are close to you and they were recommended to you for their work. You also say that you had a bad experience 
with the Plan provider. The Plan says that the reimbursement does not meet criteria because the service is not 
available and the provider is not contracted to provide these services. 
 
We decided that the Plan has to pay for intraoral - periapical first radiographic image D0220.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Specifically the Plan hasnt shown their denial reason is correct as they have not submitted 
proof that the intraoral - periapical first radiographic image had already been paid by the Plan in the previous 
12 months. Therefore, we decided that the Plan has to pay for the intraoral - periapical first radiographic image 
D0220 provided on January 12, 2023. 
 
We also decided that the Plan does not have to pay for the retainer crown - porcelain/ceramic (D6740), 
pontic - porcelain fused to high noble metal (D6240), and pontic - porcelain fused to noble metal (D6242). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the retainer 
crown - porcelain/ceramic (D6740), pontic - porcelain fused to high noble metal (D6240), and pontic - 
porcelain fused to noble metal (D6242) provided on January 12, 2023, and March 9, 2023.  
 
Your complaint about the Plans dental provider is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.