Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the periodontal scaling and root planing (D4341x2). We decided that
the Plan does not have to pay for the gingival irrigation (D4921x4), the unspecified periodontal procedure
(D4999x4), and the oral hygiene instruction (D1330).
You asked the Plan to pay for the periodontal scaling and root planing (D4341x2), the gingival irrigation
(D4921x4), the unspecified periodontal procedure (D4999x4), and the oral hygiene instruction (D1330)
provided on August 15, 2022. You say that you specifically changed dentists to maximize the Plan's benefit.
You say you had to pay out-of-pocket for the services. The Plan says that the records do not support a medical
condition which would justify the need for full mouth scaling in one visit, the gingival irrigation is not covered
when completed in conjunction with periodontal services, and the unspecified procedure and oral hygiene
instruction are not covered benefits.
We decided that the Plan has to pay for the periodontal scaling and root planing (D4341x2).
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
periodontal scaling and root planing (D4341x2) 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 periodontal scaling and root planing
(D4341x2). Our reviewer says that the periodontal scaling and root planing (D4341x2) is medically necessary.
Our physician reviewer found the documentation provided indicates the presence of areas of periodontal
pockets in all quadrants to be 4-6mm and areas of subgingival calculus. Periodontal scaling and root planing
(D4341) is medically reasonable and necessary to treat the patient's periodontal disease.
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 periodontal scaling and root planing (D4341x2) have been met. Therefore,
we decided that the Plan has to pay for the periodontal scaling and root planing (D4341x2).
We also decided that the Plan does not have to pay for the gingival irrigation (D4921x4), the unspecified
periodontal procedure (D4999x4), and the oral hygiene instruction (D1330).
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 pay for the
gingival irrigation (D4921x4), the unspecified periodontal procedure (D4999x4), and the oral hygiene
instruction (D1330).
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.