Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the additional anesthesia. We decided that the Plan does not have 
to pre-approve the surgical extraction (D7250) of tooth #19 and the therapeutic drug administration (D9612).  
 
You asked the Plan to pre-approve the surgical extraction, additional anesthesia and therapeutic drug. You say 
that these services are necessary, and you need the anesthesia for your anxiety. The Plan says that the 
extraction of the roots of tooth #19 can be accomplished non-surgically. The provider may resubmit a claim for 
the extraction of this tooth using a more appropriate procedure code. The Plan has also agreed to cover the first 
fifteen minutes of anesthesia but argues that this is sufficient time to extract the requested teeth. Additional 
anesthesia time is not medically necessary. In addition, the administration of a therapeutic drug is denied, as 
this service is not covered by your dental benefit. 
 
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 eligible dental 
services when they are medically necessary and reasonable. 
 
We decided that the Plan has to pre-approve additional anesthesia (D9223 x2).  
 
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 additional anesthesia (D9223 x2). Our 
reviewer says that it cannot be determined that additional anesthesia is not medically necessary. Our physician 
reviewer found that an initial 15-minute increment of anesthesia has already been approved, as well as a 
surgical extraction for tooth #3. The documentation does support that there is a possible need for additional 
deep sedation for the surgical extraction of tooth #3. The surgical extraction of tooth #3, which has already 
been pre-approved, is a more involved procedure and complications may arise which could lead to additional 
procedure and anesthesia time. 
 
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 additional anesthesia have been met. Therefore, we decided that the Plan has to 
pre-approve additional anesthesia (D9223 x2).  
 
We also decided that the Plan does not have to pre-approve the surgical extraction (D7250) of tooth #19 
and the therapeutic drug administration (D9612). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the administration of a therapeutic 
drug is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve the administration of a therapeutic drug (D9612). 
 
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 surgical extraction of tooth #19. Our 
reviewer says that tooth #19 does not appear to require surgical removal via a cutting procedure. Our physician 
reviewer found that the dental record and x-rays provided indicate that there is enough exposed root on this 
tooth that it can likely be removed via elevation and/or forceps. A simpler extraction procedure may be more 
appropriate as the documentation does not support the necessity for a cutting procedure to remove the exposed 
residual roots of 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 the surgical extraction have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the surgical extraction (D7250) for tooth #19. 
 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.