Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pre-approve periodontal scaling and root planing (D4341) for the upper 
right, upper left, lower right, and lower left quadrants.. We decided that the Plan does not have to pre-
approve gingival irrigation (D4921) for the upper right, upper left, lower right, and lower left quadrants.  
 
You asked the Plan to pre-approve periodontal scaling and root planing (D4341) for the upper right, upper left, 
lower right, and lower left quadrants and gingival irrigation (D4921) for the upper right, upper left, lower right, 
and lower left quadrants. You say that you are appealing with supporting records. The Plan says that for 
periodontal scaling and root planing (D4341) for the upper right, upper left, lower right, and lower left 
quadrants, the requested procedure code requires a quadrant to be designated. The Plan says that for gingival 
irrigation (D4921) for the upper right, upper left, lower right, and lower left quadrants, this service is not 
covered under the member's benefit package. 
 
We decided that the Plan has to pre-approve periodontal scaling and root planing (D4341) for the upper 
right, upper left, lower right, and lower left quadrants..  
 
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. The Plan covers periodontal 
scaling and root planing (D4341) for the upper right, upper left, lower right, and lower left quadrants when the 
services are medically necessary and reasonable. 
 
We looked at the file, and Medicare rules. The Plan denied this service saying that the procedure code requires 
a quadrant to be designated. The record shows that the provider included the requested quadrants in their 
request. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root 
planing (D4341) for the upper right, upper left, lower right, and lower left quadrants have been met. Therefore, 
we decided that the Plan has to pre-approve periodontal scaling and root planing (D4341) for the upper right, 
upper left, lower right, and lower left quadrants..  
 
We also decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the upper 
right, upper left, lower right, and lower left quadrants. 
 
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, the gingival irrigation (D4921) for the 
upper right, upper left, lower right, and lower left quadrants are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the upper 
right, upper left, lower right, and lower left quadrants. 
 
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.