Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a surgical placement of implant body: endosteal implant (D6010), 
custom fabricated abutment (D6057), and abutment supported porcelain fused to metal crown (D6059). 
 
You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, and abutment supported 
porcelain fused to metal crown. You say that the enrollee needs an implant for tooth #12 in order to chew and 
obtain adequate nutrients. You also say that the enrollee has a strong gag reflex and cannot have anything 
covering his palate, and therefore the enrollee is unable to tolerate any upper removable prosthetic. The Plan 
denied your request. The Plan says that the enrollee has either received a partial denture to replace tooth #12 
within the past sixty months or has recently been approved for a partial denture to replace tooth #12. 
 
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 endosteal 
implant, custom fabricated abutment, and abutment supported porcelain fused to metal crown 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 the endosteal implant, custom 
fabricated abutment, and abutment supported porcelain fused to metal crown. Our reviewer says that the 
implant (D6010), implant abutment (D6057) and an implant crown (D6059) meets the criteria for coverage. 
Our physician reviewer found a 3-unit fixed bridge replaced the missing tooth #12. One of the abutments (#13) 
was extracted leaving the enrollee with inadequate mastication on the left side due to missing teeth #'s 12 to 16 
on this side. The enrollee could not tolerate a maxillary removable partial denture due to an active gag reflex. 
Our reviewer also found that placement of an implant, implant abutment, and an implant crown for tooth #12 is 
reasonable and necessary to provide some mastication on the left side 
 
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 endosteal implant, custom fabricated abutment, and abutment supported 
porcelain fused to metal crown have been met. The records show that the Plan has approved a maxillary partial 
denture (D5213) for the enrollee, but not that the denture has been provided and paid for. Therefore, we 
decided that the Plan has to pre-approve a surgical placement of implant body: endosteal implant (D6010), 
custom fabricated abutment (D6057), and abutment supported porcelain fused to metal crown (D6059).  
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.