Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the partial lower denture. We decided that the Plan does not have 
to pre-approve the complete upper denture.  
 
You asked the Plan to pre-approve the partial lower denture. You say that you did not actually receive the 
dentures from 2019 and have been struggling to sort out this mess ever since.  The Plan says that there is a paid claim on file for you from October 2019 which includes a complete upper denture and a partial lower denture. These services are only covered once every five plan years. 
 
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 can cover one 
complete upper denture (D5110) every five plan years. The Plan can cover one partial lower denture, resin base 
(D5212) every five plan years. The Plan can cover one partial lower denture, cast metal framework with resin 
denture base (D5214) every five plan years. 
 
We decided that the Plan has to pre-approve the partial lower denture (D5214).  
 
The Plan denied coverage for the partial lower denture with cast metal framework and a resin denture base 
because you had a previous partial denture provided and paid for on October 28, 2019. Documentation shows 
that the Plan paid for this service at that time. However, the denture provided in 2019 was a partial lower 
denture with a resin base (D5212). The contract clearly states that D5212 is covered once every five plan years. 
The contract also clearly states that D5214 is covered once every five plan years. The contract does not state 
that you may have only one or the other every five years, or that only one partial denture of any type may be 
covered once every five years.  
 
The denture requested in this case is not the same partial denture that was provided in 2019. There is no 
documentation that you have received a partial lower denture, cast metal framework with a resin denture base 
(D5214) within the last five years. Based on this information, we decided that the Plan's rules for coverage of 
the partial lower denture have been met. Therefore, we decided that the Plan has to pre-approve a partial lower 
denture, cast metal framework with resin base (D5214). 
 
We also decided that the Plan does not have to pre-approve the complete upper denture (D5110). 
 
We looked at the file and the Plan's rules. Documentation shows that the Plan paid for a complete upper 
denture (D5110) for you in October of 2019. The Plan states that this service may only be covered once every 
five plan years. Based on this information, we decided that the denture is requested in a frequency that is not 
covered by your dental benefit. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110). 
 
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.