Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the root canal tooth #3. We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) crowns teeth 2, 3, 11 (D2740) and crown build up teeth 2, 3, 11 (D2950). You asked the Plan to pre-approve the root canal tooth #3. You say that the records should support the necessity of the service in dispute.The Plan says that the records do not support that periodontal scaling and root planing and the root canal is medically necessary while crowns and crown build-up is not covered under the plan benefits.We decided that the Plan has to pre-approve the root canal tooth #3. 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 root canal tooth #3 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 root canal tooth #3. Our physician reviewer found a review of the enrollee's dental record and radiographs indicate that root canal treatment for tooth #3, meets the criteria for coverage due to the extent of the carious lesion and the adequate bone support affording a good prognosis to restore the tooth to good 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 root canal tooth #3 have been met.Therefore, we decided that the Plan has topre-approvethe root canal tooth #3. We also decided that the Plandoes not have to pre-approveperiodontal scaling and root planing (D4341) crowns teeth 2, 3, 11 (D2740) and crown build up teeth 2, 3, 11 (D2950).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. Though the Plan offers a dental benefit in excess of Medicare coverage, crowns and crown build-upare not among those covered under this benefit.   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 periodontal scaling and root planing 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 periodontal scaling and root planing (D4341) crowns teeth 2, 3, 11 (D2740) and crown build up teeth 2, 3, 11 (D2950). Our reviewer says that this enrollee a review of the enrollee's dental record and radiographs indicate that the documentation did not provide the extent of the periodontal pockets which is necessary to substantiate the need for periodontal scaling an d root planing. Due to the lack of adequate documentation, scaling and root planing (D4341) do 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 periodontal scaling and root planing (D4341) crowns teeth 2, 3, 11 (D2740) and crown build up teeth 2, 3, 11 (D2950) have not been met.Therefore, we decided that the Plan does not have to pre-approveperiodontal scaling and root planing (D4341) crowns teeth 2, 3, 11 (D2740) and crown build up teeth 2, 3, 11 (D2950).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.