Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the surgical removal of residual roots for teeth #24 and #25. We decided that the Plan does not have to pre-approve the surgical removal of residual roots for tooth #26.

You asked the Plan to pre-approve the surgical removal of residual roots. You say that these extractions are necessary. The Plan denied your request. The Plan says that the clinical crown must be completely missing, and the root must be completely embedded in bone in order for code D7250 to be approved. Tissue bound teeth or teeth with clinical crown present are not approved at this code. The Plan states that an extraction, erupted tooth requiring removal of bone and or sectioning of tooth (D7210) could be considered for teeth #24, #25 and #26.

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 surgical removal of residual tooth roots 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 surgical removal of residual roots for teeth #24, #25 and #26.

We decided that the Plan has to pre-approve the surgical removal of residual roots for teeth #24 and #25.

Our reviewer says that the requested surgical code (D7250) would be allowable and reasonable for teeth #24 and #25. Our physician reviewer found that these two teeth are broken to the gingiva. It is likely that there will be a need for cutting of the gums and bone to remove teeth #24 and #25. There is no coronal structure remaining and only the root structure present for each tooth. According to the American Dental Association (ADA) Guide to Extraction - Tooth and Remnants, code D7250 is reasonable in this circumstance.

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 surgical removal of residual roots for teeth #24 and #25 have been met. Therefore, we decided that the Plan has to pre-approve this procedure as requested for teeth #24 and #25.

We also decided that the Plan does not have to pre-approve the surgical removal of residual roots for tooth #26.

Our reviewer says that surgical removal of residual roots is not reasonable and necessary for tooth #26. Our physician reviewer found that tooth #26 has a mostly intact clinical crown and a substantial supra-gingival structure remaining. This tooth would not be expected to require surgical removal based on the documentation provided. If tooth #26 should fracture and require surgical removal, this should be documented and submitted following the 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 a surgical removal of residual roots for tooth #26 have not been met. Therefore, we decided that the Plan does not have to pre-approve this procedure as requested for tooth #26.

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.