Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 implants, 2 prefabricated abutments, 2 abutment supported 
crowns, and 2 bone grafts. We decided that the Plan does not have to pre-approve guided tissue regeneration, 
and 1 additional prefabricated abutment, abutment supported crown, and bone graft.  
 
You asked the Plan to pre-approve dental services. You say that you need these services. The Plan denied your 
request. The Plan says guided tissue regeneration is not listed as a covered service. The Plan also says that the 
implants and related services are not medically necessary. 
 
We decided that the Plan has to pre-approve 2 implants, 2 prefabricated abutments, 2 abutment 
supported crowns, and 2 bone grafts.  
 
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 guided tissue 
regeneration, implant, prefabricated abutment, abutment supported crown, and bone graft 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 guided tissue regeneration, implant, 
prefabricated abutment, abutment supported crown, and bone graft. Our reviewer says that implant and related 
services are medically necessary. Our physician reviewer found the provided documentation indicates that the 
implants and related services are medically reasonable and necessary. 
 
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 guided tissue regeneration, implant, prefabricated abutment, abutment 
supported crown, and bone graft have been met. Therefore, we decided that the Plan has to pre-approve 2 
implants, 2 prefabricated abutments, 2 abutment supported crowns, and 2 bone grafts.  
 
We also decided that the Plan does not have to pre-approve guided tissue regeneration, and 1 additional 
prefabricated abutment, abutment supported crown, and bone graft. 
 
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 requested guided tissue 
regeneration is not among those covered under this benefit. Additionally, though prefabricated abutment, 
abutment supported crown, and bone graft are listed as covered services, they are limited to 2 per calendar year. 
Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration, and 1 additional 
prefabricated abutment, abutment supported crown, and bone graft. 
 
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.