Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the extraction of tooth #22 and removals of residual tooth roots for
tooth #'s 21, 27, and 31. We decided that the Plan does not have to pre-approve the maxillary immediate
denture, mandibular immediate denture, extractions of tooth #'s 23, 24, 25, and 26, and removal of residual
tooth roots for tooth #'s 20.
You asked the Plan to pre-approve a maxillary immediate denture (D5130), mandibular immediate denture
(D5140), extractions (D7210) of tooth #'s 22, 23, 24, 25, and 26, and removals of residual tooth roots (D2750)
for tooth #'s 20, 21, 27, and 31. The Plan says that the services do not meet the criteria for coverage.
We decided that the Plan has to pre-approve the extraction of tooth #22 and removals of residual tooth
roots for tooth #'s 21, 27, and 31.
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 extraction
of tooth #22 and removals of residual tooth roots for tooth #'s 21, 27, and 31 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 extraction of tooth #22 and
removals of residual tooth roots for tooth #'s 21, 27, and 31. Our reviewer says that the extraction of tooth #22
and removals of residual tooth roots for tooth #'s 21, 27, and 31 are medically reasonable and necessary. Our
physician reviewer found based on the condition of tooth #22, a surgical extraction is required. Our reviewer
also found that the removals of residual tooth roots for tooth #'s 21, 27, and 31 is medically reasonable because
there is no remaining coronal structure on these teeth.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the extraction of tooth #22 and removals of residual tooth roots for tooth #'s 21,
27, and 31 have been met. Therefore, we decided that the Plan has to pre-approve the extraction of tooth #22
and removals of residual tooth roots for tooth #'s 21, 27, and 31.
We also decided that the Plan does not have to pre-approve the maxillary immediate denture,
mandibular immediate denture, extractions of tooth #'s 23, 24, 25, and 26, and removal of residual tooth
roots for tooth #'s 20.
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 maxillary
immediate denture, mandibular immediate denture, extractions of tooth #'s 23, 24, 25, and 26, and removal of
residual tooth roots for tooth #'s 20 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 maxillary immediate denture,
mandibular immediate denture, extractions of tooth #'s 23, 24, 25, and 26, and removal of residual tooth roots
for tooth #'s 20. Our reviewer says that the maxillary immediate denture, mandibular immediate denture,
extractions of tooth #'s 23, 24, 25, and 26, and removal of residual tooth roots for tooth #'s 20 are not medically
necessary. Our physician reviewer found there are no existing maxillary teeth, making the maxillary immediate
denture not medically necessary. Our reviewer found that the proposed extractions for tooth #'s 23, 24, 25, and
26 are incorrect, and therefore, the immediate mandibular denture is currently not medically necessary due to
this. Our physician reviewer found that based on the condition of tooth #'s 23, 24, 25, and 26, surgical
extractions are not required. Our reviewer also found that the removal of residual tooth roots for tooth #20 is
not medically reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the maxillary immediate denture, mandibular immediate denture, extractions of
tooth #'s 23, 24, 25, and 26, and removal of residual tooth roots for tooth #'s 20 have not been met. Therefore,
we decided that the Plan does not have to pre-approve the maxillary immediate denture, mandibular immediate
denture, extractions of tooth #'s 23, 24, 25, and 26, and removal of residual tooth roots for tooth #'s 20.
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.