Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve scaling and root planing for the upper left and upper right 
quadrants. We decided that the Plan does not have to pre-approve scaling and root planing for the lower left 
and lower right quadrants.  
 
You asked the Plan to pre-approve scaling and root planing for the upper left and upper right quadrants. You 
say that you do not agree with the denial. You say that the services are necessary. You say that 2 separate 
dentists have said that the requested services are necessary. The Plan denied your request. The Plan says teeth 
must have noticeable bone loss or show on an x-ray that there is a hard substance built up on the root of the 
tooth. The Plan also says that the x-rays do not show that these issues exist. The Plan also says that the services 
are not medically necessary. 
 
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 scaling and 
root planing for the upper left and upper right quadrants when the services are medically necessary and 
reasonable. 
 
We decided that the Plan has to pre-approve scaling and root planing for the upper left and upper right 
quadrants.  
 
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 scaling and root planing for all 4 
quadrants. Our reviewer says that the scaling and root planing for the upper left and upper right quadrants is 
medically necessary. The physician reviewer found the provided documentation shows that the upper left and 
the upper right quadrants qualify for D4341, scaling and root planing for 4 or more teeth per quadrant. 
 
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 scaling and root planing for the upper left and upper right quadrants have been 
met.  Therefore, we decided that the Plan has to pre-approve scaling and root planing for the upper left and 
upper right quadrants.  
 
We also decided that the Plan does not have to pre-approve scaling and root planing for the lower left and 
lower right quadrants. 
 
Our physician reviewer says that the scaling and root planing for the lower left and lower right quadrants is not 
medically necessary. The reviewer found that the provided documentation does not show that the lower left and 
lower right quadrants have 4 or more teeth that require this service. Therefore, the reviewer found that the 
scaling and planing for the lower left and lower right quadrants are not medically reasonable or necessary. 
 
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 scaling and root planing for the lower left and lower right quadrants have not 
been met.  Therefore, we decided that the Plan does not have to pre-approve scaling and root planing for the 
lower left and lower right 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.