Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the scalings and planings of the LL and LR quadrants. We decided 
that the Plan does not have to pre-approve the scaling and planing of the UR quadrant.  
 
You asked the Plan to pre-approve periodontal scalings and root planings of four or more teeth per quadrant 
(D4341) of the LL and LR quadrants and a periodontal scaling and root planing of one to three teeth per 
quadrant (D4342) of the UR quadrant. You say that the enrollee has active periodontal gum disease present. 
You also say that there is bone loss of 4 mm and greater, and subgingival calculus are present on x-rays. The 
Plan says that periodontal scaling and root planing of one to three teeth per quadrant is not a covered benefit. 
The Plan also says that the documentation submitted does not demonstrate evidence of significant bone loss 
and/or radiographic root-surface calculus on 4 or more teeth per quadrant. 
 
We decided that the Plan has to pre-approve the scalings and planings of the LL and LR quadrants.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the scalings 
and planings of the LL and LR quadrants 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 scalings and planings of the LL and 
LR quadrants. Our reviewer says that the periodontal scalings and root planings (D4341) of the LL and LR 
quadrants are medically necessary. Our physician reviewer found the criteria for coverage for periodontal 
scaling and root planing (D4341) for the mandibular right and left quadrants have been met. 
 
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 scalings and planings of the LL and LR quadrants have been met. Therefore, 
we decided that the Plan has to pre-approve the scalings and planings of the LL and LR quadrants.  
 
We also decided that the Plan does not have to pre-approve the scaling and planing of the UR 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
scaling and planing of the UR quadrant. 
 
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.