Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the core buildups (D2950) for tooth #'s 7 and 10. We decided that the Plan does not have to pre-approve the crowns (D2752) for tooth #'s 8 and 9 and core buildups (D2950) for tooth #'s 8 and 9.

You asked the Plan to pre-approve the crowns (D2752) for tooth #'s 8 and 9 and core buildups, including any pins when required (D2950) for tooth #'s 7, 8, 9, and 10. The Plan says that the oral photos and x-rays do not show severe destruction of the teeth resulting from decay or trauma that require restoring the teeth with core buildups. The Plan also says that there is sufficient tooth structure remaining on tooth #'s 8 and 9 allowing these teeth to be restored with resin restorations and still provide a very good long-term prognosis.

We decided that the Plan has to pre-approve the core buildups (D2950) for tooth #'s 7 and 10.

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 core buildups for tooth #'s 7 and 10 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 pay for the core buildups for tooth #'s 7 and 10. Our reviewer says that tooth #'s 7 and 10 meet the criteria for coverage. Our physician reviewer found tooth #'s 7 and 10 have large restorations with recurrent caries. Our reviewer also found that tooth #10 has also had root canal treatment which weakens the coronal structure due to endodontic access and preparation. 

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 core buildups for tooth #'s 7 and 10 have been met. Therefore, we decided that the Plan has to pre-approve the core buildups (D2950) for tooth #'s 7 and 10.

We also decided that the Plan does not have to pre-approve the crowns (D2752) for tooth #'s 8 and 9 and core buildups (D2950) for tooth #'s 8 and 9.

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 crowns for tooth #'s 8 and 9 and core buildups for tooth #'s 8 and 9 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 pay for the crowns for tooth #'s 8 and 9 and core buildups for tooth #'s 8 and 9. Our reviewer says that tooth #'s 8 and 9 do not meet the criteria for coverage. Our physician reviewer found the dental record and x-rays indicate that tooth #'s 8 and 9 do not appear to have significant coronal breakdown due to caries or fracture to meet the criteria for core buildups and crowns. 

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 crowns for tooth #'s 8 and 9 and core buildups for tooth #'s 8 and 9 have not been met. Therefore, we decided that the Plan does not have to pre-approve the crowns (D2752) for tooth #'s 8 and 9 and core buildups (D2950) for tooth #'s 8 and 9.

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.