Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe crowns for tooth #'s 7, 8, and 10. We decided that the Plan does not have to pre-approvethecrown for tooth #11 and core buildups. You asked the Plan to pre-approvethe crowns for tooth #'s 7, 8, 10, and 11 and core buildups. You say that the enrollee's tooth #'s 7, 8, 10, and 11 have been severely impacted by decay as well as bruxing and clenching.The Plan says that the x-rays that were provided do not show that the crowns are medically necessary.We decided that the Planhas to pre-approvethe crowns for tooth #'s 7, 8, and 10. 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 crowns for tooth #'s 7, 8, and 10 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 crowns for tooth #'s 7, 8, and 10. Our reviewer says that crowns for tooth #'s 7, 8, and 10 are medically necessary. Our physician reviewer found the provided x-rays show significant missing structure in the coronal aspect of #7,8 and 10. Our reviewer also found that the amount of missing structure on #7,8 and 10 is greaterthan 50%, and would be considered adequate to consider a crown restoration as being necessary.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 crowns for tooth #'s 7, 8, and 10 have been met.Therefore, we decided that the Plan has to pre-approvethe crowns for tooth #'s 7, 8, and 10. We also decided that the Plandoes not have to pre-approvethe crown for tooth #11 and core buildups.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 crown for tooth #11 and core buildups when the services aremedically 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 crown for tooth #11 and core buildups. Our reviewer says that the crown for tooth #11 and core buildups are not medically necessary. Our physician reviewer found the x-rays show minimal structure loss on tooth #11. The amount of missing structure on #11 is less than 35% and would not be considered sufficient to warrant a full crown restoration. Our reviewer found that core buildups are not necessary in this instance as the wear on #7,8 and 10 would have been caused by wear, leaving little room to add any core material. Our physician reviewer also found that as there is no room for core material in this instance, there is no medical necessity for the requested core buildups.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 crown for tooth #11 and core buildups have not been met. The contract also provides a list of covered services. Core buildup (D2950) is not included on this list and is not a covered benefit.Therefore, we decided that the Plan does not have to pre-approvethe crown for tooth #11 and core buildups.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 toreview. 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.