Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the scaling and planing of the upper left quadrant. We decided that
the Plan does not have to pre-approve the crown for tooth #11 and implants for teeth #6 and 10.
You asked the Plan to pre-approve crown (D2751) for tooth #11, a periodontal scaling and root planing
(D4341) of the upper left quadrant, and surgical placements of implant bodies: endosteal implants (D6010) for
teeth #7 and 10. You say that you need 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 scaling and planing of the upper left quadrant.
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 scaling
and planing of the upper left quadrant 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 scaling and planing of the upper left
quadrant. Our reviewer says that the scaling and root planing of the upper left quadrant (D4341) meets
coverage criteria. Our physician reviewer found the scaling and root planing in the upper left arch was not
approved due to only three natural teeth in the quadrant. Our reviewer also found that the three implants present
in the arch must be considered (counted) since an implant root form is treated as a natural tooth with respect to
scaling and root planing.
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 scaling and planing of the upper left quadrant have been met. Therefore, we
decided that the Plan has to pre-approve the scaling and planing of the upper left quadrant.
We also decided that the Plan does not have to pre-approve the crown for tooth #11 and implants for
teeth #6 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 crown for
tooth #11 and implants for teeth #6 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 crown for tooth #11 and implants
for teeth #6 and 10. Our reviewer says that the crown for tooth #11 and implants for teeth #6 and 10 do not
meet coverage criteria. Our physician reviewer found tooth #11 has a crown in place which appears adequate.
Our reviewer also found that the requested implants for teeth #6 and 10 are in the same arch and according to
the rules of coverage, only one implant per arch is approved for coverage.
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 crown for tooth #11 and implants for teeth #6 and 10 have not been met.
Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #11 and implants for
teeth #6 and 10.
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.