Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve a crown on tooth #9. We decided that the Plan does not have to pre-approve a crown on tooth #19 and periodontal scaling and root planing for all quadrants.

You asked the Plan to pre-approve a crown on tooth #9. You say that these services are medically necessary. The Plan says that that the enrollee does not meet criteria for these services.

We decided that the Plan has to pre-approve a crown on tooth #9.

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 dental services 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 a crown on tooth #9. Our reviewer says that a crown for tooth #9 is medically reasonable and necessary. A crown replacement for tooth #9 meets the criteria for coverage due to the fractured porcelain causing inadequate function. Our physician reviewer found that the enrollee's condition meets criteria for coverage of the crown for tooth #9.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a crown on tooth #9 have been met. Therefore, we decided that the Plan has to pre-approve a crown on tooth #9.

We also decided that the Plan does not have to pre-approve a crown on tooth #19 and periodontal scaling and root planing for all quadrants.

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 dental services 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 a crown on tooth #19 and periodontal scaling and root planing for all quadrants. Our reviewer says that a crown on tooth #19 and periodontal scaling and root planing for all quadrants is not medically reasonable and necessary. A crown for tooth #19 does not meet the criteria for coverage due to the inadequate root canal filling and possible periapical pathology. An evaluation for retreatment of the root canal is required prior to placement of a crown. The documentation for periodontal scaling and root planing was incomplete. Periodontal charting is necessary to determine the need for this service. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of the a crown on tooth #19 and periodontal scaling and root planing for all quadrants. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Plan rules for coverage of a crown on tooth #19 and periodontal scaling and root planing for all quadrants have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #19 and periodontal scaling and root planing for all quadrants.