Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the scaling and root planing for the upper and lower left quadrants 
and the delivery of the antimicrobial agents. We decided that the Plan does not have to pre-approve the scaling 
and root planing for the upper right quadrant.  
 
You asked the Plan to pre-approve the scaling and root planing for the upper left, lower left, and upper right 
quadrants, and antimicrobial agents. You say that the services are necessary. The Plan denied your request. The 
Plan says that medical necessity was not established. 
 
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 scaling 
and root planing for the upper right quadrant when the services are medically necessary and reasonable. 
We decided that the Plan has to pre-approve the scaling and root planing for the upper and lower left 
quadrants and antimicrobial agents.  
 
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 scaling and root planing for the 
upper right quadrant. Our reviewer says that the scaling and root planing for the upper and lower left quadrants 
and the localized delivery of antimicrobial agents are medically necessary. Our physician reviewer found the 
documentation that was provided indicated that the abnormal periodontal pocketing was noted in the maxillary 
and mandibular left quadrants. The reviewer found that abnormal pocketing was associated with tooth #15 in 
which an antimicrobial agent was indicated. The reviewer found that periodontal scaling and root planing in the 
lower left and upper left quadrants and placement of an antimicrobial agent on tooth #15 is reasonable and 
necessary. 
 
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 scaling and root planing for the upper and lower left quadrants, and the 
delivery of the antimicrobial agents have been met. Therefore, we decided that the Plan has to pre-approve the 
scaling and root planing for the upper and lower left quadrants and the delivery of the antimicrobial agents.  
 
We also decided that the Plan does not have to pre-approve the scaling and root planing for the upper 
right quadrant. 
 
The reviewer also found that the periodontal pocketing in the upper right quadrant appears to be within normal 
limits. Therefore, the reviewer found that the scaling and root planing for the upper left quadrants is not 
reasonable or necessary. 
 
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 scaling and root planing for the upper right quadrant have not been met.  
Therefore, we decided that the Plan does not have to pre-approve the scaling and root planing for the upper 
right quadrant. 
 
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.