Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the dental anesthesia services requested (CPT codes D9222 and D9223) when used during the approved dental extractions for tooth number 4, 5, and 11. We decided that the Plan does not have to pre-approve dental extractions for tooth number 2, 3, 13, 15, 18, and 31 or the dental anesthesia services requested for use during those denied extractions.

You asked the Plan to pre-approve the dental extractions and the dental anesthesia services. You say that you need 9 extractions due to the teeth all being infected. You say that you have severe health risks such as gastric bypass, recovered alcoholism, liver disease, back surgery and fibromyalgia. You say that you have a high tolerance for pain, but that the current pain you have is too much to handle.

The Plan says that the benefit for dental extractions has been exhausted. The Plan says that the dental anesthesia services being requested are not a covered benefit under the enrollee's plan.

We decided that the Plan has to pre-approve the dental anesthesia services requested for use during the approved dental extractions.

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 records show that the dental anesthesia services being requested are those represented by CPT codes D9222 and D9223. The Plan's denial reason is that the requested anesthesia services are not a covered benefit under the enrollee's contract. However, we found that these CPT codes are specifically listed as a covered benefit under the enrollee's contract, when performed in conjunction with covered services. The Plan has not substantiated their denial reason. Therefore, we decided that the Plan has to pre-approve the requested dental anesthesia services when performed in conjunction with the dental extraction procedures which were approved.

We also decided that the Plan does not have to pre-approve dental extraction services of tooth number 2, 3, 13, 15, 18, and 31 or the dental anesthesia services requested to be used during these denied extraction procedures.

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's coverage of dental extractions is limited to 3 procedures per calendar year. The records show that the Plan has approved coverage of dental extraction services for tooth number 4, 5, and 11. This means that your request for additional dental extractions in the 2021 calendar year would exceed the benefit allowance for this type of service. The Plan's coverage of dental anesthesia is limited to necessary anesthesia used during a covered service. This means that the requested anesthesia services would not be eligible for coverage when used during the non-covered extraction procedures. Therefore, we decided that the Plan does not have to pre-approve the dental extraction services for tooth number 2, 3, 13, 15, 18, and 31 or the dental anesthesia requested for use during those denied extraction procedures.

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.