Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crown for tooth #23. We decided that the Plan does not have to 
pre-approve the crown for tooth #29 and core buildups for tooth #'s 23 & 29.  
 
You asked the Plan to pre-approve the crowns (D2740) for tooth #'s 23 & 29 and core buildups, including any 
pins when required (D2950) for tooth #'s 23 & 29. You say that the current filling on tooth #23 is too large to 
stay in place. You also say that tooth #29 has a very large filling and fractured cusp, and when it is removed the 
prep will require a core buildup. The Plan says that the records do not show very large losses of tooth structure 
from decay or trauma, or not enough tooth left to hold the crown. The Plan also says that the documentation 
does not show that there is decay or fracture of more than 50% of the enrollee's tooth, or a broken off cusp. 
 
We decided that the Plan has to pre-approve the crown for tooth #23.  
 
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 #23 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 crown for tooth #23. Our reviewer 
says that the crown for tooth #23 is medically necessary. Our physician reviewer found tooth #23 appears to be 
rather small mesio-distally on the radiograph likely due to prior restoration. Our reviewer found that the incisal, 
mesial and distal appears to have been restored and this presents a concern for stress buildup on the incisor 
when chewing. Our physician reviewer also found that as there appears to be about 50% compromise of the 
structure on tooth #23 and it is in a stress bearing area it would be reasonable to place a crown on it given the 
circumstances 
 
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 #23 have been met. Therefore, we decided that the Plan has 
to pre-approve the crown for tooth #23.  
 
We also decided that the Plan does not have to pre-approve the crown for tooth #29 and core buildups for 
tooth #'s 23 & 29. 
 
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 #29 and core buildups for tooth #'s 23 & 29 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 crown for tooth #29 and core 
buildups for tooth #'s 23 & 29. Our reviewer says that the crown for tooth #29 and core buildups for tooth #'s 
23 & 29 are not medically necessary. Our physician reviewer found tooth #29 appears radiographically to have 
an existing two surface restoration and some minimal recurrent decay. There might be some extension of the 
old restoration to one of the cusps, but given the records provided it cannot be concluded that an entire cusp is 
fractured.  Our reviewer found that there is insufficient evidence of the need to reinforce #29 using a crown 
restoration.  If there is visible cracking of the cusp an intra-oral photograph may be submitted to supplement 
the x-ray view to aid in such a determination. Our physician reviewer also found that there is insufficient 
missing structure on tooth #23 as to require a core buildup.  A standard crown preparation would be sufficiently 
retentive, without any additional core buildup material in this case. 
 
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 #29 and core buildups for tooth #'s 23 & 29 have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #29 and core 
buildups for tooth #'s 23 & 29. 
 
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.