Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pre-approve core buildup (D2950), resin-based composite fillings (D2393), and crowns 
(D2740). You say that you believe these services should be covered. The Plan says that these services are not 
covered by the Plan and your maximum dental benefit will be exhausted. 
 
We decided that the Plan has to pre-approve core buildup (D2950), tooth #3.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 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 core 
buildups up to a calendar year maximum benefit of $1,000. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says that, at the time of their decision, $848.10 of the $1,000 maximum 
yearly benefit had been met. The Plan says that your maximum benefit will become exhausted after the Plan 
pays an anticipated $115.90 toward an amalgam-based filling. However, the Plan has not shown that your 
dental maximum benefit is currently exhausted and cannot hold you liable for dollar amounts that have not yet 
been paid or covered. Therefore, the Plan has not shown that its decision to deny authorization for the core 
buildup is correct or justified. Therefore, we decided that the Plan has to pre-approve core buildup.  
 
We also decided that the Plan does not have to pre-approve resin-based composite fillings (D2393) on 
teeth # 2, 16, and 18, and crown (D2751) on tooth #3. 
 
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, the requested items or services are not 
among those covered under this benefit. Teeth # 2, 16, and 18 are posterior teeth, meaning that the white 
resin-based fillings will instead be processed as silver fillings. Therefore, the Plan has substituted the requested 
resin-based fillings (D2393) with amalgam-based fillings (D2160). The requested crown for tooth #3 is being 
placed on a posterior tooth; therefore, the Plan has substituted the requested crown code of D2740 with a crown 
that is appropriate for a base metal filling (D2751). Please contact the Plan for more information about the 
services the Plan approved as alternatives to your request. Therefore, we decided that the Plan does not have to 
pre-approve the requested fillings and crown. 
 
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.