Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated, for tooth #7 and #10 (D7210) and periodontal scaling and root planing - four or more teeth per quadrant of the LR and LL quadrants (D4341), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.
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 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 the dental services. Our physician reviewer found on the provided panoramic x-ray it can be seen that #17 and #10 are erupted teeth with significant amount of remaining coronal structure. The radiographs do not show any significant amount of bone loss in the lower left or right quadrants on four or more teeth. Only tooth #17 has any noted loss of bone support, which is noted by not extensive. The submitted treatment code of D4341 requires there are four or more involved teeth in a quadrant. In this case, there are less than four teeth that are periodontally involved in any quadrant, and as such the provided code is not appropriate. The Plan provisions for extractions state, "Documentation needed for authorization procedure: Appropriate radiographs showing clearly the adjacent and opposing teeth should be submitted for authorization review: bitewings, periapicals or panorex. Treatment rendered under emergency conditions, when authorization is not possible, will still require that appropriate radiographs showing clearly the adjacent and opposing teeth be submitted with the claim for review for payment. Narrative demonstrating medical necessity." In this instance, there is no narrative that demonstrates
medical necessity. As for periodontal treatment, the plan provides "Criteria A minimum of four (4) teeth affected in the quadrant. Periodontal charting indicating abnormal pocket depths in multiple sites. Additionally, at least one of the following must be present: 1) Radiographic evidence of root surface calculus. 2) Radiographic evidence of noticeable loss of bone support." In this case, there are an insufficient number of teeth showing loss of bone support in any quadrant to qualify for the treatment under the supplied code. Given the lack of support for the requested treatment there is no medical necessity for the requested treatment. 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 dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated, for tooth #7 and #10 (D7210) and periodontal scaling and root planing - four or more teeth per quadrant of the LR and LL quadrants (D4341), for the enrollee.