Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the pontic for tooth #11. We decided that the Plan does not have to pre-approve the pontics for tooth #'s 23, 24, 25, and 26, and retainer crowns for tooth #'s 10, 12, 22, and 27.

You asked the Plan to pre-approve pontics (D6242) for tooth #'s 11, 23, 24, 25, and 26, and retainer crowns (D6740) for tooth #'s 10, 12, 22, and 27. You say that you have 8 teeth that your dentist wants to replace, and you would like these services to be approved for coverage. The Plan says that these services are not medically necessary.

We decided that the Plan has to pre-approve the pontic 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 the pontic 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 the pontic for tooth #11. Our reviewer says that the replacement of tooth #11 (an anterior tooth) meets criteria for coverage of a fixed bridge. Our physician reviewer found you have one missing maxillary anterior tooth, and your overall status justifies the need with the extraction of the tooth. 

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 the pontic for tooth #11 have been met. Therefore, we decided that the Plan has to pre-approve the pontic for tooth #11.

We also decided that the Plan does not have to pre-approve the pontics for tooth #'s 23, 24, 25, and 26, and retainer crowns for tooth #'s 10, 12, 22, 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 pontics for tooth #'s 23, 24, 25, and 26, and retainer crowns for tooth #'s 10, 12, 22, 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 pontics for tooth #'s 23, 24, 25, and 26, and retainer crowns for tooth #'s 10, 12, 22, and 27. Our reviewer says that the pontics (D6242) for tooth #'s 23, 24, 25, and 26, and retainer crowns (D6740) for tooth #'s 10, 12, 22, and 27 do not meet the criteria for coverage for a fixed bridge. Our physician reviewer found the pontics (D6242) for tooth #'s 23, 24, 25, and 26, and retainer crowns (D6740) for tooth #'s 10, 12, 22, and 27 do not meet coverage criteria, because more than two adjacent mandibular anterior teeth are to be replaced. 

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 the pontics for tooth #'s 23, 24, 25, and 26, and retainer crowns for tooth #'s 10, 12, 22, and 27 have not been met. Therefore, we decided that the Plan does not have to pre-approve the pontics for tooth #'s 23, 24, 25, and 26, and retainer crowns for tooth #'s 10, 12, 22, and 27.

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.