Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the endosteal implant, prefabricated abutment, and abutment supported porcelain/ceramic crown. We decided that the Plan does not have to pre-approve the all metal crown for tooth #29.
You asked the Plan to pre-approve the all metal crown, endosteal implant, prefabricated abutment, and abutment supported porcelain/ceramic crown. You say that you have difficulty chewing and would like these services to be covered. The Plan says that it is not medically necessary to replace the cap on your tooth. The Plan also says that your dentist has asked to replace more than one tooth in this part of your mouth with an implant, and the implant is denied.
We decided that the Plan has to pre-approve the endosteal implant, prefabricated abutment, and abutment supported porcelain/ceramic crown.
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 endosteal implant, prefabricated abutment, and abutment supported porcelain/ceramic crown 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 endosteal implant, prefabricated abutment, and abutment supported porcelain/ceramic crown. Our reviewer says that the documentation supports the need for an implant, implant abutment and implant supported crown for area #30. Our physician reviewer found there was no indication in the documents that another implant was placed in the area or planned for the mandibular 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 endosteal implant, prefabricated abutment, and abutment supported porcelain/ceramic crown have been met. Therefore, we decided that the Plan has to pre-approve the endosteal implant, prefabricated abutment, and abutment supported porcelain/ceramic crown.
We also decided that the Plan does not have to pre-approve the all metal crown for tooth #29.
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 all metal crown 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 all metal crown for tooth #29. Our reviewer says that the criteria for a crown for tooth #29 has not been met. Our physician reviewer found the documentation provided did not address why the crown on tooth #29 needed replacement. 
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 all metal crown have not been met. Therefore, we decided that the Plan does not have to pre-approve the all metal crown for tooth #29.
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.