Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has pre-approve the overdenture  complete maxillary (D5863) and overdenture  
complete mandibular (D5865). We decided that the Plan does not have pre-approve surgical access to an 
implant body (D6011), surgical placement of implant body (D6010), custom fabricated abutment (D6057), 
guided tissue regeneration (D4266), and bone graft at time of implant placement for tooth #'s 7, 10, 20, 22, 27 
and 29 (D6104).  
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan says that says these services are not covered under the benefit package and your dentist failed to provide a 
label for the tooth #s to tell us which tooth the service is being done for. 
 
We decided that the Plan has pre-approve the overdenture  complete maxillary (D5863) and 
overdenture  complete mandibular (D5865).  
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request for the overdenture  complete maxillary (D5863) and overdenture  complete 
mandibular (D5865). This service is covered in the Plans dental benefits. The Plans states they need to know if 
the dentures are for the top or bottom jaw, but the codes themselves include that information. (D5863) is 
maxillary, or top, and (D5865) is mandibular, or bottom. Theyre also complete dentures, so tooth numbers are 
not needed. 
 
Therefore, we decided that the Plan has pre-approve the overdenture  complete maxillary (D5863) and 
overdenture  complete mandibular (D5865).  
 
We also decided that the Plan does not have pre-approve surgical access to an implant body (D6011), 
surgical placement of implant body (D6010), custom fabricated abutment (D6057), guided tissue 
regeneration (D4266), bone graft at time of implant placement tooth #'s 7, 10, 20, 22, 27 and 29 (D6104). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, surgical access to an implant body 
(D6011), surgical placement of implant body (D6010), custom fabricated abutment (D6057), bone graft at time 
of implant placement for tooth #'s 7, 10, 20, 22, 27 and 29 (D6104) are not among those covered under this 
benefit. 
 
The Plan covers guided tissue regeneration (D4266) when medically necessary. Since these specific tooth 
numbers were not requested, it cannot be determined if this service is medically necessary.  
Therefore, we decided that the Plan does not have pre-approve surgical access to an implant body (D6011), 
surgical placement of implant body (D6010), custom fabricated abutment (D6057), guided tissue regeneration 
(D4266), bone graft at time of implant placement for tooth #'s 7, 10, 20, 22, 27 and 29 (D6104). 
 
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.