Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve surgical extraction of tooth 6 (D7210). We decided that the Plan does not have to pre-approve surgical extraction of roots with bone for teeth 1 and 3 (D7250).
You asked the Plan to pre-approve surgical extraction of tooth 6 (D7210). You say that the enrollee stated he is currently experiencing hypersensitivity and pain due to severe decay on several teeth and is incapable of eating and chewing correctly. The Plan says that the documentation does not support the code requested. A less severe extraction code for each tooth noted would be considered.
We decided that the Plan has to pre-approve surgical extraction of tooth 6 (D7210).
We also decided that the Plan does not have to pre-approve surgical extraction of roots with bone for teeth 1 and 3 (D7250).
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 surgical extraction of tooth 6 (D7210) 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 surgical extraction of tooth 6 (D7210). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found he supplied radiographs indicate that a root tip is seen just under the gumline with no surrounding bone, which means the root is attached by soft tissue only. The remaining root on #3 has minimal bone remaining but clearly appears to be the result of a broken down tooth, and not a residual root from an attempted extraction. In both cases, #1 and #3, the code of D7250 is not appropriate as #1 does not require bone removal, and #3 had not had a prior extraction attempt. Tooth #6 does have a notable loss of structure in the cervical third and has full bone support and it is likely that the tooth will require bone removal to extract the root. Therefore the D7210 code for #6 would be medically necessary, and the D7250 codes for #1 and #3 would not be medically 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 surgical extraction of tooth 6 (D7210) have been met. Therefore, we decided that the Plan has to pre-approve surgical extraction of tooth 6 (D7210). We also we decided that the Plan's rules for coverage of surgical extraction of roots with bone for teeth 1 and 3 (D7250).have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical extraction of roots with bone for teeth 1 and 3 (D7250).
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.