Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes coverage of emergency oral evaluation problem focused exams once every 12 months. The Plan contract says that oral evaluation problem focused exams are considered a Class 2 Basic Service. The Plan contract says that enrollees must pay a 50% coinsurance for Class 2 Basic Services after a $100 deductible. You can find this information on page 76 of the Plan's 2022 Evidence of Coverage. 

The Plan contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes coverage of intraoral x-ray imaging under the Class 2 Basic Service benefit category. The Plan contract says that enrollees must pay a 50% coinsurance for Class 2 Basic Services after a $100 deductible. You can find this information on page 76 of the Plan's 2022 Evidence of Coverage.

The Plan contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes coverage of core buildup and crowns under the Class 3 Major Service benefit category. The Plan contract says that enrollees must pay a 50% coinsurance for Class 3 Major Services after a $100 deductible. You can find this information on pages 76 through 78 of the Plan's 2022 Evidence of Coverage.

The Plan contract also says that if the Plan determined that a less expensive alternate procedure, service, or course of treatment can be performed in place of a proposed treatment to correct a dental condition and the alternate treatment will produce a professionally satisfactory result, then the maximum the Plan will allow will be the charge for the less expensive treatment. You can find this information on page 75 of the Plan's 2022 Evidence of Coverage.