Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (four or more teeth per quadrant, for four quadrants) (D4341), two porcelain/ceramic crowns (D2740) and two cast posts and fillings for a crown (D2952).

You asked the Plan to pre-approve the dental services. You say that your dental provider says these services are necessary. The Plan denied your request. The Plan says they cannot approve the periodontal scaling and root planing because there is no evidence of significant bone loss or radiographic root surface calculus on four or more teeth per quadrant. This service is not medically necessary. Additionally, the Plan cannot cover the porcelain/ceramic crowns or the cast posts and fillings for the crowns because these services are not covered by Medicare or by the Plan's supplemental dental benefit.

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 dental services included in the benefit when the services are medically necessary and reasonable.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested porcelain/ceramic crowns (D2740) and cast posts and fillings for the crowns (D2952) are not among the items or services covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve these services. However, we found that the periodontal scaling and root planing for four or more teeth per quadrant (D4341) is a service that is eligible for coverage under this benefit pending a medical necessity review.

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 periodontal scaling and root planing of four or more teeth per quadrant for all four quadrants. Our reviewer says that there is no apparent medical necessity for this service. Our physician reviewer found that the supplied full series of radiographs show no notable loss of bone in any quadrant. There is no tartar noted on root surfaces (which are not exposed), and minimal tartar noted on surfaces above the attachment level.

The supplied periodontal charting does indicate areas of pocketing of up to 6 mm of depth, with 3 mm being considered the normal measurement for a periodontal pocket. Periodontal scaling and root planing can only be performed where there has been a loss of clinical attachment such that root surfaces have been exposed to the oral environment.

In this instance, as there is no apparent loss of clinical attachment, the root surfaces are not accessible for plaque and tartar accumulation leaving no ability to perform scaling and root planing procedures. Given the radiographic information provided, there would be no necessity for the requested procedures.

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 dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (four or more teeth per quadrant, for four quadrants) (D4341), two porcelain/ceramic crowns (D2740) and two cast posts and fillings for a crown (D2952).