Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a core buildup for tooth #19. We decided that the Plan does not 
have to pre-approve crowns and core buildup for teeth #s 18 and 20.  
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan says 
that there is enough of each tooth to repair with a filling. 
 We decided that the Plan has to pre-approve a core buildup for tooth #19.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. The contract says that the Plan covers certain dental services as a supplemental (extra) 
benefit. For that reason, the Plans coverage rules apply in this case. The Plan covers dental services when the 
services are medically reasonable and necessary. 
 
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 for a buildup for tooth #19. Our reviewer says that this 
dental services is medically reasonable and necessary. Our physician reviewer found due to significant 
breakdown of tooth #19 due to caries, a buildup is necessary to provide a strong base for good retention and 
stability of the approved crown restoration on tooth #19. 
 
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 core buildup for tooth #19 have been met. Therefore, we decided that the Plan 
has to pre-approve a core buildup for tooth #19.  
 
We also decided that the Plan does not have to pre-approve crowns and core buildup for teeth #s 18 and 
20. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. The contract says that the Plan covers certain dental services as a supplemental (extra) 
benefit. For that reason, the Plans coverage rules apply in this case. The Plan covers dental services when the 
services are medically reasonable and necessary. 
 
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 for the rest of the dental services. Our reviewer says 
that the requested services are not medically reasonable or necessary. A review of the dental record and 
radiographs indicate that teeth #s 18 and 20 do not appear to have significant coronal breakdown due to caries 
or fracture to meet the criteria for buildups and crown restorations. Our physician reviewer found that the 
documentation provided does not meet the criteria for coverage for buildups and crown restorations for teeth #s 
18 and 20.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of crowns and core buildup for teeth #s 18 and 20 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve crowns and core buildup for teeth #s 18 and 20. 
 
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.