Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe resin-based fillings (D2330, D2335, D2391) and the amalgam-based fillings (D2140, D2150). We decided that the Plan does nothave to pre-approvethe partial upper dentures (D5213), the partial lower dentures (D5214), the comprehensive periodontal evaluations (D0180), the pulp vitality test (D0460), the crown (D2740), the core build-up (D2950), the endodontic therapy (D3310), the root canal obstruction treatment (D3331), the surgical procedures for isolation of tooth with rubber dam (D3910), the canal preparation (D3950), the periodontal maintenance (D4910), the gingival irrigation (D4921), and the application of desensitizing medicament (D9910). You asked the Plan to pre-approvethe multiple dental services. You say that you want to get your dentures fixed because they do not fit causing you to bleed profusely and you are unable to eat.The Plan says that the benefit limitation is exhausted for the partial upper dentures (D5213), partial lower dentures (D5214), the resin-based fillings (D2330, D2335, D2391) and the amalgam-based fillings (D2140, D2150). The Plan says that the comprehensive periodontal evaluations (D0180), the pulp vitality test (D0460), the crown (D2740), the core build-up (D2950), the endodontic therapy (D3310), the root canal obstruction treatment (D3331), the surgical procedures for isolation of tooth with rubber dam (D3910), the canal preparation (D3950), the periodontal maintenance (D4910), the gingival irrigation (D4921), and the application of desensitizing medicament(D9910) are not covered benefits.We decided that the Planhas to pre-approvethe resin-based fillings (D2330, D2335, D2391) and the amalgam-based fillings (D2140, D2150). The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There were no records submitted to support that the Plan has paid forresin-based fillings (D2330, D2335, D2391) orthe amalgam-based fillings (D2140, D2150)to exhaust the benefit. Therefore, we decided that the Plan has to pre-approve the resin-based fillings (D2330, D2335, D391) and the amalgam-based fillings (D2140, D2150).We also decided that the Plandoes not have to pre-approvethe partial upper dentures (D5213), the partial lower dentures (D5214), the comprehensive periodontal evaluations (D0180), the pulp vitality test (D0460), the crown (D2740), the core build-up (D2950), the endodontic therapy (D3310), the root canal obstruction treatment (D3331), the surgical procedures for isolation of tooth with rubber dam (D3910), the canal preparation (D3950), the periodontal maintenance (D4910), the gingival irrigation (D4921), and the application of desensitizing medicament (D9910).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, there is a benefit limit for the partial upper dentures (D5213) and the partial lower dentures (D5214). The plan clearly states that only one upper partial denture and one lower partial denture is covered every 5 calendaryears. The records show the Plan paid for an upper partial denture (D5213) and a lower partial denture on May 7, 2019, which exhausted the benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive periodontal evaluations (D0180), the pulp vitality test (D0460), the crown (D2740), the core build-up (D2950), the endodontic therapy (D3310), the root canal obstruction treatment (D3331), the surgical procedures for isolation of tooth with rubber dam (D3910), the canalpreparation (D3950), the periodontal maintenance (D4910), the gingival irrigation (D4921), and the application of desensitizing medicament(D9910)are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approvethe partial upper dentures (D5213), the partial lower dentures (D5214), the comprehensive periodontal evaluations (D0180), the pulp vitality test (D0460), the crown (D2740), the core build-up (D2950), the endodontic therapy (D3310), the root canalobstruction treatment (D3331), the surgical procedures for isolation of tooth with rubber dam (D3910), the canal preparation (D3950), the periodontal maintenance (D4910), the gingival irrigation (D4921), and the application of desensitizing medicament (D9910).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.