Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve core buildup including pins for tooth 13. We decided that the Plan does not have to pre-approve core buildup including pins for tooth 12.
You asked the Plan to pre-approve core buildup including pins for tooth 13. You say that the records provided should support medical necessity of the service in dispute. The Plan says that the requested service is not medically necessary as there are sufficient tooth structure present.
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 core buildup including pins 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 core buildup including pins for tooth 13. Our reviewer says that this enrollee partially meets the medically necessary criteria for the core build-up. Our physician reviewer found the provider noted that initially it was anticipated that endodontic treatment was needed on both teeth, but that they were able to be restored without root canal therapy. The panoramic x-ray provided shows a heavily broken down #13 with a broken out or decayed mesial aspect and a large distal amalgam restoration. Tooth #12 had a large distal composite restoration. The single periapical x-ray appears to show both teeth with the old restorations removed, and on that film it appears that #13 would have sufficient missing structure (50%) that a core would be indicated to assist in the retention of the final crown that had been
approved. Tooth #12 appears to have sufficient remaining structure such that a core would not be necessary to aid in the retention of a crown. Therefore, given the supplied records, a core buildup D2950 would be medically necessary for tooth #13 only.
We decided that the Plan has to pre-approve core buildup including pins for tooth 13.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of core buildup including pins for tooth 13 have been met. Therefore, we decided that the Plan has to pre-approve core buildup including pins for tooth 13.
We also decided that the Plan does not have to pre-approve core buildup including pins for tooth 12.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of core buildup including pins for tooth 12 have not been met. Therefore, we decided that the Plan does not have to pre-approve core buildup including pins for tooth 12.
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.