Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 24, 2021.
You asked the Plan to pay for dental services. You say that food was getting lodged in your pre-existing dental
bridge with every bite you took, and you needed the bridge to be either replaced or repaired. The Plan denied
your request. The Plan says that there is no evidence of decay or a missing crown that would support the need
for replacement of the current crowns. There is also insufficient documentation to determine if the services
provided on February 24, 2021, met the Plan's rules for coverage.
The rules say that the provider, supplier or beneficiary, as appropriate, must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment. Medicare rules
also say that if an enrollee asks for a standard pre-service appeal but gets the service before the Plan makes a
decision, the appeal should be dismissed. When the claim for the service is submitted, the Plan will decide
whether to pay for it. If the Plan does not pay for the service, you can appeal.
In this case, the record shows that you requested five porcelain/ceramic crowns (D2740) be covered by the
Plan. These services were denied on February 12, 2021. You say that you received the denial but did not
receive further guidance on how to solve your problem, so you sought help from a dentist who did not accept
your insurance but was willing to help. The dentist performed unspecified services and told you that sometimes
it is better to replace the bridge in the future. You also say that your insurance agent asked you to request that
the Plan reimburse the cost of services provided by this provider, and you included a receipt that shows the
name of the dentist's office and the total amount you paid. You say that you are still concerned about bridge
replacement in the future.
Although the initial request was for prior authorization, the Reconsideration in this case reviewed the services
that were already provided on February 24, 2021. It is unclear from the request what services where provided.
Generally, dental services are provided and then billed with specific, clearly defined procedure codes which
allow the Plan to determine whether the service is eligible for coverage under your benefits and the amount of
payment that can be made. There also appears to be some discrepancy in this request, as prior authorization
was requested for five standard porcelain/ceramic crowns, but work relating to a fixed bridge is discussed in
your appeal. Typically, fixed bridges use a different type of crown in combination with other components. The
specific items and services that were provided for you are unclear. Because of this, the proof of payment is also
incomplete. Itemized receipts and office claim forms are necessary for the Plan to determine how much was
paid for which service, and whether the services are eligible for coverage.
In addition, if the provided services are eligible for coverage, a medical necessity review cannot be conducted
with the quality of x-rays provided. The images are illegible. Because Medicare only pays for services that are
deemed medically reasonable and necessary, we cannot determine if the services provided met coverage
criteria.
There is insufficient information to determine whether payment should be made for the requested services.
Therefore, we decided that the Plan does not have to pay for the dental services provided on February 24, 2021.
Your complaint about the services that are eligible for coverage under your dental benefit is not a valid appeal
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare
does not permit us to make a decision about these types of complaints.