Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the extraction (D7140) for tooth #29. We decided that the Plan 
does not have to pre-approve the extraction (D7140) for tooth #32.  
 
You asked the Plan to pre-approve extractions (D7140) for tooth #29 and #32. You say that it is medically 
necessary for you to get your teeth extracted. The Plan says that the extractions are denied because of the lack 
of medical necessity. 
  We decided that the Plan has to pre-approve the extraction (D7140) for tooth #29.  
 
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. 
 
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 service. Our reviewer says 
that the extraction (D7140) for tooth #29 is medically necessary. Our physician reviewer found that from the 
supplied documentation it appears that tooth #29 would be reasonable to extract. There is sufficient damage to 
tooth #29 that extraction would be a reasonable alternative to attempting restoration. 
 
Tooth #29 appears to have need for extraction if further restoration or a crown is not possible. This clinical 
decision would appear to be appropriate and allowable under the Plan. 
 
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 service have been met. Therefore, we decided that the Plan has to 
pre-approve the extraction (D7140) for tooth #29.  
 
We also decided that the Plan does not have to pre-approve the extraction (D7140) for tooth #32. 
 
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. 
 
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 extraction (D7140) for tooth #32. 
Our reviewer says that the extraction (D7140) for tooth #32 is not medically necessary. Our physician reviewer 
found that from the supplied documentation it appears that tooth #32 is uncertain due to the lack of diagnostic 
quality x-rays. There is no clear x-ray of tooth #32 to allow for a proper determination of the need to remove 
that tooth. 
 
Tooth #32's condition is not clear due to poor diagnostic quality x-rays.  Without need for extraction being 
documented, there can be no need for the procedure under the Plan.  
 
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 extraction (D7140) for tooth #32 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the extraction (D7140) for tooth #32. 
 
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.