Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve endodontic therapy (root canal) (D3320) and a core buildup procedure (D2950) for tooth #28. We decided that the Plan does not have to pre-approve an alveoloplasty, 1-3 teeth per quadrant (D7321), four semi-precision attachment abutments (D6052) and four surgical placements of implant bodies (D6010).
You asked the Plan to pre-approve these dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the endodontic therapy and core buildup are denied because the tooth in question is not restorable due to extensive decay at or below the bone level. The alveoloplasty is denied because it is a service that is included as part of the approved extractions. Semi-precision attachment
abutments and surgical placement of implant bodies are denied because they are not covered by Medicare or by the Plan's supplemental dental 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 can cover some of the requested services when they are medically necessary and reasonable.
We decided that the Plan has to pre-approve endodontic therapy (root canal) (D3320) and a core buildup procedure (D2950) for tooth #28.
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 root canal and core buildup procedure for tooth #28. Our reviewer says that the root canal and core buildup meet the criteria for coverage. Our physician reviewer found that the patient's dental record and radiographs indicate that tooth #28 has gross caries and is in need of root canal treatment. The bone support is adequate. It is our reviewer's opinion that a root canal and core buildup are reasonable and necessary to retain tooth #28.
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 a root canal and core buildup procedure have been met. Therefore, we decided that the Plan has to pre-approve endodontic therapy (root canal) (D3320) and a core buildup procedure (D2950) for tooth #28.
We also decided that the Plan does not have to pre-approve an alveoloplasty, 1-3 teeth per quadrant (D7321), four semi-precision attachment abutments (D6052) and four surgical placements of implant bodies (D6010).
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 alveoloplasty, but it was unclear from the file which quadrant required the requested service. Due to the lack of documentation indicating where the alveoloplasty is needed, a complete review of the service cannot be completed. Therefore, we decided that the Plan does not have to pre-approve the alveoloplasty, 1-3 teeth per quadrant (D7321).
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested semi-precision attachment abutments and surgical placements of implant bodies are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four semi-precision attachment abutments (D6052) and four surgical placements of implant bodies (D6010).
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.