Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services on tooth #3. We decided that the Plan does not have to pay 
for the services on tooth #2.  
 
You asked the Plan to pay for the services. You say that there was not enough tooth structure to support the 
crown so they built the core. The Plan says that the prognosis appears to be uncertain and the benefits are not 
recommended for this service. 
 
We decided that the Plan has to pay for the services on tooth #3.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Evidence of Coverage does not state that porcelain/ceramic crowns are not customary treatment. This 
means that the Plan did not clearly disclose a ceramic crown would be covered instead of the porcelain/ceramic 
crown. Based on this information, we decided that Medicare rules for coverage of the services have been met. 
Therefore, we decided that the Plan has to pay for the services on tooth #3.  
 
We also decided that the Plan does not have to pay for the services on tooth #2. 
 
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 they are medically 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 services on tooth #2. Our reviewer says that 
there is no clinical record information as to the need for a crown on tooth #2, only for tooth #3. Our physician 
reviewer found that tooth #2 has an existing two surface restoration may require involvement of a third surface, 
with only about 20% of the structure currently involved. The only documentation regarding tooth #2 is the 
supplied x-ray, and the film does not support the need for the requested full coverage crown. In general, a 
crown is considered when 50% or more of the structure is missing and the tooth needs to gain strength from the 
crown. In cases where there are only two or three involved surfaces it is uncommon to require a full coverage 
crown in order to maintain the tooth in the dental arch. As there are no clinical notes or other supporting 
documentation regarding the need for a crown on tooth #2, it would not be considered a reasonable or 
necessary service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services on tooth #2 have not been met. Therefore, we decided that the Plan 
does not have to pay for the services on tooth #2. 
 
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.