Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the extractions of tooth #'s 12, 13, 21, 22, 23, 24, 25, 26, and 27. We decided that the Plan does not have to pre-approve the extractions of tooth #'s 2, 3, 4, 5, 6, 7, 8, 14, 15, 20, and 28. You asked the Plan to pre-approvethe extractions of tooth #'s 2, 3, 4, 5, 6, 7, 8, 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 27, and 28. The Plan says that the x-rays were not clear. The Plan also says that the Plan's dentist needs to look at a clear x-ray of the enrollee's teeth to decide if the service is medically necessary.We decided that the Planhas to pre-approvethe extractions of tooth #'s 12, 13, 21, 22, 23, 24, 25, 26, and 27. 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 the extractions of tooth #'s 12, 13, 21, 22, 23, 24,25, 26, and 27 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 the extractions of tooth #'s 12, 13, 21, 22, 23, 24, 25, 26, and 27. Our reviewer says that extractions of tooth #'s 12, 13, 21, 22, 23, 24, 25, 26, and 27 are medically necessary. Our physician reviewer found there is a request for surgical removal of all remaining teeth in the dental arches. There are some photos and a panoramic x-ray supplied for review. Our reviewer also found that tooth #'s 12, 13, 21, 22, 23, 24, 25, 26, and 27 are the only teeth that clearly are sufficiently embedded in bone without remaining coronal structure as to likely require surgical removal.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 extractions of tooth #'s 12, 13, 21, 22, 23,24, 25, 26, and 27 have been met.Therefore, we decided that the Plan has to pre-approvethe extractions of tooth #'s 12, 13, 21, 22, 23, 24, 25, 26, and 27. We also decided that the Plandoes not have to pre-approvethe extractions of tooth #'s2, 3, 4, 5, 6, 7, 8, 14, 15, 20, and 28.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 the extractions of tooth #'s 2, 3, 4, 5, 6, 7, 8, 14, 15, 20, and 28 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 the extractions of tooth #'s 2, 3, 4, 5, 6, 7, 8, 14, 15, 20, and 28. Our reviewer says that extractions of tooth #'s 2, 3, 4, 5, 6, 7, 8, 14, 15, 20, and 28 are not medically necessary. Our physician reviewer found there is a request for surgical removal of all remaining teeth in the dental arches. The remaining teeth cannot be clearly seen to require a flap and bone removal, with most appearing to be remnants embedded in soft tissue. Our reviewer also found that unless supported by clinical notes at the time of removal, the supplied records do not support the requests for surgical removal of #2, 3, 4, 5, 6, 7, 8,14, 15,20,or 28 at this time.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 extractions of tooth #'s 2, 3, 4, 5, 6, 7, 8, 14, 15, 20, and 28 have not been met.Therefore, we decided that the Plan does not have to pre-approvethe extractions of tooth #'s 2, 3, 4, 5, 6, 7, 8, 14, 15, 20, and 28.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.