Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the scaling and planing of the LL quadrant. We decided that the 
Plan does not have to pre-approve the crown for tooth #18 and scalings and planings of the LR, UL, and UR 
quadrants.  
 
You asked the Plan to pre-approve the crown for tooth #18 and scalings and planings of the LL, LR, UL, and 
UR quadrants. The Plan says that the documentation does not demonstrate evidence of significant bone loss 
and/or radiographic root surface calculus on 4 or more teeth per quadrants that is required to qualify the 
enrollee for the periodontal scalings and root planings. The Plan also says that the documentation demonstrates 
furcation involvement on tooth #18, and a crown is therefore denied. 
 
We decided that the Plan has to pre-approve the scaling and planing of the LL quadrant.  
 
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 scaling 
and planing of the LL 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 LL 
quadrant. Our reviewer says that the scaling and planing of the LL quadrant meets coverage criteria. Our 
physician reviewer found the lower left quadrant has sufficient indication that there is periodontal disease with 
associated bone loss that would benefit from scaling and root planing. Our reviewer found that the treatment 
for periodontal disease is the debridement of the root surface from toxins.  The root surface needs to be 
accessible in order to perform the debridement, and this is only possible when there is a loss of attachment 
thereby exposing the root surface.  Our physician reviewer also found that only the lower left quadrant can be 
seen to have root surfaces available to debride, along with abnormal pocket depths in multiple sites, and is the 
only quadrant that qualifies for the periodontal scaling and root planing procedure. 
 
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 LL quadrant have been met. Therefore, we 
decided that the Plan has to pre-approve the scaling and planing of the LL quadrant.  
 
We also decided that the Plan does not have to pre-approve the crown for tooth #18 and scalings and 
planings of the LR, UL, and UR 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 crown for 
tooth #18 and scalings and planings of the LR, UL, and UR 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 crown for tooth #18 and scalings 
and planings of the LR, UL, and UR quadrants. Our reviewer says that the crown for tooth #18 and scalings 
and planings of the LR, UL, and UR quadrants does not meet coverage criteria. Our physician reviewer found 
tooth #18 had a prior crown restoration which have succumbed to recurrent decay.  The radiographic view 
appears to show slight bone loss in the area of the furcation, which could compromise the long term prognosis 
of this tooth.  Our reviewer found that, as there is no specific clinical information as to the depth of the 
furcation by clinical measurements, a crown would have to be deemed not reasonable or medically necessary 
until it could be demonstrated that the furcation is manageable, maintainable, and clinically stable. Our 
physician reviewer also found that the UL, LR, and UR quadrants are not seen to have significant bone loss, 
and as such would not meet the criteria for 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 crown for tooth #18 and scalings and planings of the LR, UL, and UR 
quadrants have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown for 
tooth #18 and scalings and planings of the LR, UL, and UR quadrants. 
 
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.