Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the reconstruction of jaw, lower jawbone graft, dental surgery procedure, and special supplies. We decided that the Plan does not have to pre-approve coverage of OON services at the in-network level of benefits.
You asked the Plan to pre-approve the reconstruction of jaw, lower jawbone graft, dental surgery procedure, and special supplies. You say that this service is medically necessary and should be covered at the in-network rate. The Plan says that these services are not eligible for coverage under the medical benefit.
We decided that the Plan has to pre-approve the reconstruction of jaw, lower jawbone graft, dental surgery procedure, and special supplies.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. The rules also say that Medicare will not pay for dental services.
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 reconstruction of jaw, lower jaw bone graft, dental surgery procedure, and special supplies. Our reviewer says that the service is medically necessary. Our physician reviewer found the services are the result of a medical event leading to the severe facial trauma. The services indicated are medically reasonable and necessary to return the patient to adequate masticatory function. 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 reconstruction of jaw, lower jaw bone graft, dental surgery procedure, and special supplies have been met. Therefore, we decided that the Plan has to pre-approve the reconstruction of jaw, lower jawbone graft, dental surgery procedure, and special supplies.
We also decided that the Plan does not have to pre-approve coverage of OON services at the in-network level of benefits.
The Plan follows Medicare rules. Medicare rules say that the Plan can charge different prices for services received at in-network and OON providers. The contract with the Plan says that if the enrollee uses an OON provider, their share of the costs for their covered services may be higher. We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to grant you an exception to receive care from the OON provider at in-network level of benefits. Based on this information, we decided that Medicare rules for coverage of coverage of OON services at an in-network level of benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve coverage of OON services at the in-network level of benefits.
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.