Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the panoramic jaw x-ray (70355), complex motion x-ray of both
sides of body (76102), and orthodontic cephalogram (70350). We decided that the Plan does not have to preapprove
the occlusal orthotic device (D7880).
You asked the Plan to pre-approve the panoramic jaw x-ray (70355), complex motion x-ray of both sides of
body (76102), orthodontic cephalogram (70350), and occlusal orthotic device (D7880). You say that you need
these services to be approved for coverage. The Plan says that this device is not reasonable and necessary when
used to treat TMJ.
We decided that the Plan has to pre-approve the panoramic jaw x-ray (70355), complex motion x-ray of
both sides of body (76102), and orthodontic cephalogram (70350).
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and
necessary.
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 panoramic jaw x-ray (70355),
complex motion X-ray of both sides of body (76102), and orthodontic cephalogram (70350). Our reviewer says
that the panoramic jaw x-ray (70355), complex motion x-ray of both sides of body (76102), and orthodontic
cephalogram (70350) are needed to arrive at the diagnosis and etiology of the TMJ issue and meet the criteria
for coverage. Our physician reviewer found the rules of coverage state that treatment for temporomandibular
joint disorders may be covered if the condition is caused by a medical disorder. Our reviewer found that the
services required to arrive at a correct diagnosis and etiology, meet the criteria for coverage. Our physician
reviewer also found that in this case the appropriate radiographic service such as panoramic radiographs,
complex motion radiographs and cephalograms are reasonable and necessary.
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 panoramic jaw x-ray (70355), complex motion x-ray of both sides of body
(76102), and orthodontic cephalogram (70350) have been met. Therefore, we decided that the Plan has to preapprove
the panoramic jaw x-ray (70355), complex motion x-ray of both sides of body (76102), and
orthodontic cephalogram (70350).
We also decided that the Plan does not have to pre-approve the occlusal orthotic device (D7880).
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and
necessary.
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 occlusal orthotic device (D7880).
Our reviewer says that the use of an orthotic appliance (D7880) to treat the dental condition (low vertical
dimension) does not meet the criteria for coverage. Our physician reviewer found the diagnosis was articular
disc disorder caused by low vertical dimension. Our reviewer also found that this is a dental disorder, and the
orthotic device to raise the vertical dimension would be used to treat the dental condition which does not meet
the criteria for coverage.
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 occlusal orthotic device (D7880) have not been met. Therefore, we decided
that the Plan does not have to pre-approve the occlusal orthotic device (D7880).
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.