Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crown for tooth #7. We decided that the Plan does not have to 
pre-approve the crown for tooth #19 and endodontic therapy for tooth #19.  
 
You asked the Plan to pre-approve the crowns (D2750) for tooth #'s 7 and 19 and endodontic therapy (D3330) 
for tooth #19. You say that you are worried about your teeth, you are in pain, and are swollen. The Plan says 
that the services are not medically necessary. 
 
We decided that the Plan has to pre-approve the crown for tooth #7.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the crown for 
tooth #7 when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crown for tooth #7. Our reviewer 
says that a crown for tooth #7 (D2750) meets the criteria for coverage. Our physician reviewer found a 
significant portion of the natural coronal tooth structure of tooth #7 has been compromised. A crown 
restoration is reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown for tooth #7 have been met. Therefore, we decided that the Plan has 
to pre-approve the crown for tooth #7.  
 
We also decided that the Plan does not have to pre-approve the crown for tooth #19 and endodontic 
therapy for tooth #19. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the crown for 
tooth #19 and endodontic therapy for tooth #19. when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crown for tooth #19 and endodontic 
therapy for tooth #19. Our reviewer says that the crown and endodontic therapy for tooth #19 are not medically 
reasonable and necessary. Our physician reviewer found tooth #19 appears to have severe periodontal issues 
(deep infrabony pockets on the mesial and distal aspect and bifurcation issues). Our reviewer found that the 
prognosis for retention of tooth #19 is poor. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown for tooth #19 and endodontic therapy for tooth #19. have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #19 and endodontic 
therapy for tooth #19. 
 
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.