Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the periodontal scaling and root planing of the lower right quadrant. We decided that the Plan does not have to pre-approve the maxillary partial denture and mandibular partial denture.
You asked the Plan to pre-approve the periodontal scaling and root planing of the lower right quadrant, a maxillary partial denture, and a mandibular partial denture. The Plan says that the documentation submitted does not demonstrate evidence of significant bone loss (2.5+ mm from the cementoenamel junction) and/or radiographic root surface calculus on 4 or more teeth per quadrant that is required to qualify the enrollee for this procedure under the Plan. The Plan also says that the maxillary partial denture and mandibular partial denture are not covered under the enrollee's benefit plan.
We decided that the Plan has to pre-approve the periodontal scaling and root planing of the lower right quadrant.
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 periodontal scaling and root planing of the lower right 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 periodontal scaling and root planing of the lower right quadrant. Our reviewer says that the service meets coverage criteria. Our physician reviewer found the periodontal charting does indicate multiple sites with pocket readings in excess of 4mm around four or more teeth in the lower right quadrant. The supplied x-rays do indicate notable bone loss around tooth #'s 28, 29, 30, and 31. Our reviewer found that the premolars appear to have bony defects on the buccal and lingual aspects of teeth #28 and #29 seen on the periapical views but not as clearly on the bitewing views. Our reviewer also found that, given the number of teeth involved (28, 29, 30, and 31), and the noted bone loss as seen on the x-rays, there appears to be medical necessity for the requested procedure of periodontal scaling and root planing for the lower right 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 the periodontal scaling and root planing of the lower right quadrant have been met. Therefore, we decided that the Plan has to pre-approve the periodontal scaling and root planing of the lower right quadrant.
We also decided that the Plan does not have to pre-approve the maxillary partial denture and mandibular partial denture.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the maxillary partial denture and mandibular partial denture.
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.