Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this condition does not meet required clinical criteria to establish 
medical necessity. 
 
We decided that the Plan has to pre-approve the pontic - porcelain fused to high noble metal tooth #14 
(D6240), and core buildup, including any pins when required tooth #13, 15, 31 (D2950). 
 
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 the dental 
services. 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 dental services. Our reviewer says 
that the documentation provided meets the criteria for coverage for core buildup (D2950) of teeth #'s 13 and 15 
is medically reasonable and necessary to provide adequate support for crown restorations. Our reviewer found 
the documentation indicates the presence of a defective bridge in this area. Recurrent caries are noted in teeth 
#s 13 and 15. Removal of the bridge is necessary to remove the caries and to restore the teeth to proper 
function. Core build up (D2950) of teeth #s 13 and 15 is medically reasonable and necessary to provide 
adequate support for crown restorations. A new bridge replacing tooth #14 with a pontic (D6240) is medically 
reasonable and necessary to provide adequate masticatory function and support. 
 
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 dental services. have been met. Therefore, we decided that the Plan has to 
pre-approve the pontic - porcelain fused to high noble metal tooth #14 (D6240), and core buildup, including 
any pins when required tooth #13, 15, 31 (D2950). 
 
We also decided that the Plan does not have to pre-approve the bone graft at time of implant placement 
tooth #14 (D6104), retainer crown - porcelain fused to high noble metal tooth #'s 13, 15 (D6750), implant 
supported porcelain/ceramic crown tooth #14 (D6065), prefabricated abutment  includes modification 
and placement (D6056), implant supported porcelain/ceramic crown tooth #14 (D6010). 
 
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 items or services are not 
among those covered under this benefit.  
 
 Therefore we decided that the plan does not have to pre-approve the bone graft at time of implant placement 
tooth #14 (D6104), retainer crown - porcelain fused to high noble metal tooth #'s 13, 15 (D6750), implant 
supported porcelain/ceramic crown tooth #14 (D6065), prefabricated abutment  includes modification and 
placement (D6056), implant supported porcelain/ceramic crown tooth #14 (D6010). 
 
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.