Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a core buildup, including any pins (D2950) for teeth numbers 6, 7, 
10, 11, pontic - porcelain/ceramic (D6245) for teeth numbers 8 and 9, and a retainer crown - porcelain/ceramic 
(D6740) for teeth numbers 6, 7, 10, 11. 
 
You asked the Plan to pre-approve a core buildup, including any pins (D2950) for teeth numbers 6, 7, 10, 11, 
pontic - porcelain/ceramic (D6245) for teeth numbers 8 and 9, and a retainer crown - porcelain/ceramic 
(D6740) for teeth numbers 6, 7, 10, 11. You say that are appealing with supporting records. The Plan denied 
your request. The Plan says that multiple outreaches were made to obtain documentation as to why the 
treatment being requested was medically necessary. The Plan also says that the provider has not submitted the 
required documentation to support the need for treatment. The Plan also says that this does not meet the plan 
requirements that require all treatment to be 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 a core 
buildup, including any pins (D2950) for teeth numbers 6, 7, 10, 11, pontic - porcelain/ceramic (D6245) for 
teeth numbers 8 and 9, and a retainer crown - porcelain/ceramic (D6740) for teeth numbers 6, 7, 10, 11 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 a core buildup, including any pins 
(D2950) for teeth numbers 6, 7, 10, 11, pontic - porcelain/ceramic (D6245) for teeth numbers 8 and 9, and a 
retainer crown - porcelain/ceramic (D6740) for teeth numbers 6, 7, 10, 11. Our reviewer says that this meets 
criteria. Our physician reviewer found the documentation provided meets the criteria for coverage for a fixed 
bridge replacing the current bridge, which was fractured when the patient fell sustaining trauma to the face and 
original bridge. The physician reviewer also found that coverage for core buildups (D2950) for teeth numbers 
6, 7, 10, and 11, retainer crowns (D6740) for teeth numbers 6, 7, 10 and 11, and pontics (D6245) for teeth 
numbers 8 and 9 meet the criteria for coverage of medically reasonable and 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 a core buildup, including any pins (D2950) for teeth numbers 6, 7, 10, 11, 
pontic - porcelain/ceramic (D6245) for teeth numbers 8 and 9, and a retainer crown - porcelain/ceramic 
(D6740) for teeth numbers 6, 7, 10, 11 have been met. Therefore, we decided that the Plan has to pre-approve a 
core buildup, including any pins (D2950) for teeth numbers 6, 7, 10, 11, pontic - porcelain/ceramic (D6245) for 
teeth numbers 8 and 9, and a retainer crown - porcelain/ceramic (D6740) for teeth numbers 6, 7, 10, 11.  
 
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.