Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the complete maxillary denture and mandibular partial denture. We decided that the Plan does not have to pre-approve the crown.
You asked the Plan to pre-approve the crown for tooth #21, complete maxillary denture and mandibular partial denture. The Plan says that they did not receive the x-rays they requested, which are needed to make a determination of medical necessity.
We decided that the Plan has to pre-approve the complete maxillary denture and mandibular partial denture.
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 complete maxillary denture and mandibular partial denture 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 complete maxillary denture and mandibular partial denture. Our reviewer says that the complete maxillary denture and mandibular partial denture are medically necessary. Our physician reviewer found the upper arch as seen on the panoramic x-ray is edentulous, and the lower arch is partially edentulous and has treatment planned for extraction of tooth #'s 23, 24, 25 and 26. There is sufficient remaining bone around abutment teeth for a partial denture. 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 complete maxillary denture and mandibular partial denture have been met. Therefore, we decided that the Plan has to pre-approve the complete maxillary denture and mandibular partial denture.
We also decided that the Plan does not have to pre-approve the crown.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. The rules state that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. For that reason, the Plan's coverage rules apply in this case. 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. Our reviewer says that the crown for tooth #21 cannot be determined to be medically necessary at this time with the current supplied records. Our physician reviewer found tooth #21 appears to be restored, but it cannot be discerned from the x-ray the extent of missing or restored structure. In general crowns are considered where 50% or more of the structure has been lost to damage, decay or fracture or there is a need for the remaining tooth to gain strength from a full coverage restoration. Our reviewer found that the panoramic x-ray is not diagnostic enough to determine if there is a need for a crown on #21. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown.