Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown for tooth #31 and core buildup for tooth #31. We decided 
that the Plan does not have to pre-approve a crown for tooth #11 and core buildup for tooth #11.  
 
You asked the Plan to pre-approve crowns (D2752) for tooth #'s 11 and 31 and core buildups, including any 
pins when required (D2950) for tooth #'s 11 and 31. You say that tooth #31 is for your partials because it holds 
your partials in. You also say that tooth #11 is a front tooth is for biting things and needs protection. The Plan 
says that tooth #'s 11 and 31 are healthy, and the x-rays do not show that they have significant breakdown. 
 
We decided that the Plan has to pre-approve a crown for tooth #31 and core buildup for tooth #31.  
 
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 a crown for 
tooth #31 and core buildup for tooth #31 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 a crown for tooth #31 and core buildup 
for tooth #31. Our reviewer says that a crown for tooth #31 and core buildup for tooth #31 is medically 
necessary. Our physician reviewer found a core buildup (D2950) and crown (D2752) is medically reasonable 
for tooth #31, which is to serve as an abutment for a partial denture. 
 
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 crown for tooth #31 and core buildup for tooth #31 have been met. Therefore, 
we decided that the Plan has to pre-approve a crown for tooth #31 and core buildup for tooth #31.  
 
We also decided that the Plan does not have to pre-approve a crown for tooth #11 and core buildup for 
tooth #11. 
 
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 a crown for 
tooth #11 and core buildup for tooth #11 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 a crown for tooth #11 and core buildup 
for tooth #11. Our reviewer says that a crown for tooth #11 and core buildup for tooth #11 are not medically 
necessary. Our physician reviewer found the possible periapical radiolucency associated with tooth #11 should 
be evaluated and treated before a permanent restoration is placed in tooth #11. 
 
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 crown for tooth #11 and core buildup for tooth #11 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #11 and core buildup for 
tooth #11. 
 
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.