Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve endosteal implants on tooth #12 and 13 (D6010), prefabricated 
abutments on tooth #12 and 13 (D6056), abutment supported crowns on tooth #12 and 13 (D6058), and bone 
grafts at the time of the implant placement on tooth #12 and 13 (D6104). We also decided that the Plan does 
not have to pre-approve a crown on tooth #28 (D2750), core build up on tooth #28 (D2950), a prefabricated 
abutment on tooth #14 (D6056), and an abutment supported crown on tooth #14 (D6058).  
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary. The Plan denied your request. The Plan says that the endosteal implants, prefabricated abutments, 
abutment supported crowns, and bone grafts are not medically necessary. The Plan also says that your benefit 
for crowns (D2750) has been exhausted, therefore the requested core build up is not covered. 
 
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 implants, 
abutments, abutment supported crowns, and bone grafts when the services are medically necessary and 
reasonable. 
 
We decided that the Plan has to pre-approve endosteal implants on tooth #12 and 13 (D6010), 
prefabricated abutments on tooth #12 and 13 (D6056), abutment supported crowns on tooth #12 and 13 
(D6058), and bone grafts at the time of the implant placement on tooth #12 and 13 (D6104).  
 
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 implants, abutments, abutment 
supported crowns, and bone grafts. Our reviewer says that the coverage criteria for these services has been met. 
Our physician reviewer found that the documentation indicates that your masticatory function is compromised 
due to multiple missing teeth (tooth #'s 12, 13 14, 30 and 31). It is medically reasonable and necessary to 
replace the missing teeth to provide adequate mastication. 
 
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 implants, abutments, abutment supported crowns, and bone grafts have been 
met. Therefore, we decided that the Plan has to pre-approve endosteal implants on tooth #12 and 13 (D6010), 
prefabricated abutments on tooth #12 and 13 (D6056), abutment supported crowns on tooth #12 and 13 
(D6058), and bone grafts at the time of the implant placement on tooth #12 and 13 (D6104). 
 
We also decided that the Plan does not have to pre-approve a crown on tooth #28 (D2750), core build up 
on tooth #28 (D2950), a prefabricated abutment on tooth #14 (D6056), and an abutment supported 
crown on tooth #14 (D6058). 
 
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, certain limitations apply. The record 
shows your benefit for crowns (D2750) was exhausted on this authorization request. Without the approval of a 
crown on tooth #28 the associated core build up on tooth #28 is not covered. 
 
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 an abutment and an abutment supported 
crown. Our reviewer says that the coverage criteria for these services has not been met. Our physician reviewer 
found that there is no indication of an implant placed on tooth #14, therefore a prefabricated abutment and an 
abutment supported crown are not medically necessary. 
 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 an abutment and an abutment supported crown have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a crown on tooth #28 (D2750), core build up on tooth 
#28 (D2950), a prefabricated abutment on tooth #14 (D6056), and an abutment supported crown on tooth #14 
(D6058). 
 
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.