Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120), core buildups, including any pins when required (D2950) for tooth #'s 3, 6, and 7, and crowns (D2740) for tooth #'s 3, 6, and 7.
You asked the Plan to pre-approve the fixed partial denture sectioning, core buildups, and crowns. You say that you would like to be able to get your crown and bridge put together and put on because you do not want to go around without teeth. You also say that you cannot afford to pay what will be charged. The Plan denied your request. The Plan says fixed partial denture sectioning is not a covered benefit under your plan. The Plan also says that your benefit for a crown for tooth #7 has been exhausted. The Plan also says that the core buildups for tooth #'s 3, 6, and 7 and crowns for tooth #'s 3 and 6 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 Plan's coverage rules apply in this case. The Plan covers core buildups and crowns 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 core buildups and crowns. Our reviewer says that the core buildups (D2950) for tooth #'s 3, 6, and 7, and crowns (D2740) for tooth #'s 3 and 6 are not medically necessary at this time. Our physician reviewer found core buildups are only needed where there is insufficient structure to retain a crown, and this has not been shown and is not readily determinable with existing bridge units. Our reviewer found that it is currently unknown what condition the teeth are in under the existing bridge, so it would not be prudent to plan to replace a 2-year-old bridge with new crowns and implants where the possibility exists to either recement it, section it and just placing implant, or locating the loose unit and addressing just that unit. It has not been shown that the 2-year-old bridge has failed to the extent that it must be fully replace and each unit have new crowns along with implants on the missing teeth. Our physician reviewer also found that it does not appear at this time that the proposed treatment plan to fully replace a 2-year-old fixed bridge is reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Fixed partial denture sectioning (D9120) is not a covered service. The contract says that crowns (D2740) are limited to one procedure per tooth per 60 months. The record shows that tooth #7 has been treated with a crown in the last two years and your crown benefit for tooth #7 has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the fixed partial denture sectioning, core buildups, and crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120), core buildups, including any pins when required (D2950) for tooth #'s 3, 6, and 7, and crowns (D2740) for tooth #'s 3, 6, and 7.