Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe endodontic therapy for tooth #'s 6 & 11. We decided that the Plan does not have to pre-approvethe crowns fortooth #'s 6 & 11. You asked the Plan to pre-approvethe endodontic therapy and crowns. The Plan says that that the submitted information does not show evidence of active recurrent decay, and esthetics is not included as a need for replacement of theexisting crowns. The Plan also says that the prognosis for these teeth is poor due to significant bone loss  We decided that the Planhas to pre-approvethe endodontic therapy for tooth #'s 6 & 11. 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 endodontic therapy for tooth #'s 6 & 11 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 endodontic therapyfor tooth #'s 6 & 11. Our reviewer says thatthe root canals for tooth #'s 6 & 11 meet criteria for coverage.Our physician reviewer found thatthe bone support appears adequate and the prognosis is adequate. Removal of these teeth would be needed if the root canals were not done. Removal of these abutment retainers would seriously compromise the existing bridgework.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the endodontic therapy for tooth #'s 6 & 11have been met.Therefore, we decided that the Plan has to pre-approvethe endodontic therapy for tooth #'s 6 & 11. We also decided that the Plandoes not have to pre-approvethe crowns for tooth #'s 6 & 11.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 crowns for tooth #'s 6 & 11 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 crowns for tooth #'s 6 & 11. Our reviewer says that the crowns are not medically necessary. Our physician reviewer found thatthe crowns in place on teeth #'s 6 and 11 appear adequate and do not meet the criteria for coverage at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the crowns for tooth #'s 6 & 11 have not been met.Therefore, we decided that the Plan does not have to pre-approvethe crowns for tooth #'s 6 & 11.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 decideto open the case again, we will send you a letter.