Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the core buildups and crowns for tooth #'s 14 & 21. We decided that the Plan does not have to pre-approve the core buildup and crown for tooth #17.
You asked the Plan to pre-approve the core buildups for tooth #'s 14, 17, & 21 and the crowns for tooth #'s 14, 17, & 21. You say that tooth #17 has a large defective filling with recurrent caries undermining the mesiolingual (ML) cusp. You also say that tooth #'s 14 and 21 have extensive caries, a broken cusp on tooth #21, and broken cusps on tooth #14 due to undermining. The Plan says that the documentation does not show these services are medically necessary.
We decided that the Plan has to pre-approve the core buildups and crowns for tooth #'s 14 & 21.
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 core buildups and crowns for tooth #'s 14 & 21 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 core buildups for tooth #'s 14 & 21 and the crowns for tooth #'s 14 & 21. Our reviewer says that core buildups and crowns are medically necessary for tooth #'s 14 & 21. Our physician reviewer found tooth #'s 14 & 21 meet the criteria for coverage for core buildups (D2950) and crowns (D2751) due to the significant coronal breakdown. 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 core buildups for tooth #'s 14 & 21 and the crowns for tooth #'s 14 & 21 have been met. Therefore, we decided that the Plan has to pre-approve the core buildups and crowns for tooth #'s 14 & 21.
We also decided that the Plan does not have to pre-approve the core buildup and crown for tooth #17.
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 core buildup and crown for tooth #17 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 core buildup for tooth #17 and the crown for tooth #17. Our reviewer says that the core buildup and crown are not medically necessary for tooth #17. Our physician reviewer found tooth #17 does not exhibit the coronal breakdown to meet the criteria for coverage for a core buildup and crown restoration. 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 core buildup for tooth #17 and the crown for tooth #17 have not been met. Therefore, we decided that the Plan does not have to pre-approve the core buildup and crown for tooth #17.
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.