Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve crown - porcelain/ceramic (D2740) Tooth #7. We decided that 
the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) Tooth #14 and core buildup, 
including any pins when required (D2950) Tooth #14.   
You asked the Plan to pre-approve crown - porcelain/ceramic (D2740) Tooth #7 and 14 and core buildup, 
including any pins when required (D2950) Tooth #14. You say that that you do not want the tooth pulled you 
would like a crown. The Plan says that the x-ray shows advanced tooth loss on tooth #7 and 14. These teeth do 
not have adequate healthy bone to support crowns. 
 
We decided that the Plan has to pre-approve crown - porcelain/ceramic (D2740) Tooth #7.  
 
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 rules also say that 
Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent 
Review Entity (IRE). 
 
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 dental services. Our physician reviewer 
found tooth #7 has sufficient structural damage as to require a crown for proper restoration; therefore, this is 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of dental services have been met. Therefore, we decided that the Plan has to pre-
approve crown - porcelain/ceramic (D2740) Tooth #7.  
 
We also decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) Tooth 
#14 and core buildup, including any pins when required (D2950) Tooth #14. 
 
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 crown - porcelain/ceramic (D2740) 
Tooth #14 and core buildup, including any pins when required (D2950) Tooth #14. Our physician reviewer 
found tooth #14 is found not medically necessary for a crown because it has moderate structural damage which 
can be restored with a conventional restoration.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of crown - porcelain/ceramic (D2740) Tooth #14 and core buildup, including any 
pins when required (D2950) Tooth #14 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve crown - porcelain/ceramic (D2740) Tooth #14 and core buildup, including any pins when required 
(D2950) Tooth #14. 
 
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.