Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to preapprove a crown for tooth number 13. We decided that the Plan does not 
have to preapprove a crown for tooth number 14 and a full mouth debridement.  
 
You asked the Plan to preapprove the crowns for teeth number 13 and 14 and a full mouth debridement. You 
say that the requested dental services are medically necessary. The Plan says that the dental services are not 
medically necessary. 
 
We decided that the Plan has to preapprove a crown for tooth number 13.  
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services 
include services to improve the functioning of a malformed body member. 
 
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 preapprove a crown for tooth number 13. Our 
reviewer says that the replacement crown for tooth #13 is medically necessary. The provided radiographs do 
not clearly show the neck of tooth #13, however the intraoral photos do show a discoloration at the margin of 
the existing crown which appears to be attributable to decay at the margin. Marginal decay compromises the 
tooth and the existing crown, and the appropriate treatment would be to replace the crown.  
 
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 number 13 have been met. Therefore, we decided that the 
Plan has to preapprove the crown for tooth number 13.  
 
We also decided that the Plan does not have to preapprove a crown for tooth number 14 and a full 
mouth debridement. 
 
The Plan follows Medicare rules. The rules say that medically necessary services are those that are reasonable 
and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include 
services to improve the functioning of a malformed body member. 
 
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 preapprove a crown for tooth number 14 and a full 
mouth debridement. Our reviewer says that the crown for tooth #14 and the full mouth debridement are not 
medically necessary. The crown on tooth #14 does not appear to be medically necessary. Tooth #14 has 
existing restorations, and radiographically there does not appear to be any clear issue. If there is a defective 
margin and light decay, the tooth is most appropriately restored with a conventional restoration as there is no 
apparent cuspal involvement and less than 50% compromised tooth structure which are the common 
considerations for the need for a crown. The full mouth debridement is not appropriate as the code is designed 
to allow for cleaning of inflamed tissues so that a comprehensive exam can be performed. The American 
Dental Association (ADA) provides a description of this code: " full mouth debridement to enable a 
comprehensive oral evaluation and diagnosis on a subsequent visit. Full mouth debridement involves the 
preliminary removal of plaque and calculus that interferes with the ability of the dentist to perform a 
comprehensive oral evaluation. Not to be completed on the same day as a comprehensive oral evaluation, a 
detailed and extensive oral evaluation, or a comprehensive periodontal evaluation."  In this case there was a full 
exam and a periodontal charting performed, and therefore the code would not be the correct one as a 
comprehensive exam was performed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a crown for tooth number 14 and a full mouth debridement have not been met. 
Therefore, we decided that the Plan does not have to preapprove a crown for tooth number 14 and a full mouth 
debridement. 
 
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.