Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five bone replacement grafts (D4263 x5), three biologic 
materials to aid in soft and osseous tissue regeneration (D4265 x3), two endosteal implants (D6010 x2), two 
custom fabricated abutments (D6057 x2), two abutment supported porcelain fused to metal crowns (D6059 x4), 
osseous surgeries (D4260) of four quadrants, and periodontal scalings and root planings (D4341) of four 
quadrants. 
 
You asked the Plan to pre-approve the bone replacement grafts, biologic materials, endosteal implants, custom 
fabricated abutments, abutment supported porcelain fused to metal crowns, osseous surgeries, and scalings and 
planings. You say that these services are very important for the care of your teeth. The Plan denied your 
request. The Plan says bone replacement graft, biologic materials, endosteal implant, custom fabricated 
abutment, and abutment supported porcelain fused to metal crown are not covered under the enrollee's benefit 
plan. The Plan also says that the osseous surgeries and scalings and planings are not medically necessary. 
 
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 osseous 
surgery and scaling and planing 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 osseous surgeries and scalings and 
planings. Our reviewer says that the current claim is not proper for the requested procedures and there is no 
medical necessity for the D4341 or D4260 codes. Our physician reviewer found there is a limited area that 
exhibits any bone loss, notably in the tooth #18 to #19 area. The majority of the areas seen on the x-ray appear 
to have normal attachment and no bony defects. The code D4341 is reserved for situations where there are four 
or more affected areas in any one quadrant. For less than four teeth affected, a different code should be used. 
Our reviewer found that here is no justification in the documentation for four quadrants of scaling and root 
planing under the D4341 code. Our physician reviewer also found that osseous surgery is not indicated in any 
quadrant given the x-rays provided at this time, and certainly not before scaling and root planing procedures if 
indicated as required under the Plan criteria. 
 
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 bone replacement grafts, biologic materials, endosteal implants, custom 
fabricated abutments, abutment supported porcelain fused to metal crowns, osseous surgeries, and scalings and 
planings have not been met. Therefore, we decided that the Plan does not have to pre-approve five bone 
replacement grafts (D4263 x5), three biologic materials to aid in soft and osseous tissue regeneration (D4265 
x3), two endosteal implants (D6010 x2), two custom fabricated abutments (D6057 x2), two abutment supported 
porcelain fused to metal crowns (D6059 x4), osseous surgeries (D4260) of four quadrants, and periodontal 
scalings and root planings (D4341) of four quadrants.