Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the prefabricated abutment (D6056x2) and the abutment supported 
porcelain/ceramic crown (D6058x2). We decided that the Plan does not have to pre-approve the surgical 
placement of implant body (D6010x2).  
 You asked the Plan to pre-approve the surgical placement of implant body (D6010x2), the prefabricated 
abutment (D6056x2), and the abutment supported porcelain/ceramic crown (D6058x2). You say that the 
treatment is medically necessary. The implants on teeth #s 5 and 12 will improve masticatory function 
significantly compared with implants on teeth #s 18 and 19. The Plan says that the frequency limit for the 
surgical placement of implant body (D6010x2) has already been met. The prefabricated abutment (D6056x2) 
and the abutment supported porcelain/ceramic crown (D6058x2) are not medically necessary. 
 
We decided that the Plan has to pre-approve the prefabricated abutment (D6056x2) and the abutment 
supported porcelain/ceramic crown (D6058x2).  
 
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 the 
prefabricated abutment (D6056x2) and the abutment supported porcelain/ceramic crown (D6058x2) 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 prefabricated abutment (D6056x2) 
and the abutment supported porcelain/ceramic crown (D6058x2). Our reviewer says that the services are 
medically necessary. Our physician reviewer found the documentation provided indicates the presence of 
implant body placement in areas #5 and #12. The completion of the restorative treatment in area #5 and 12 
requires the placement of the implant abutment and implant supported crowns. 
 
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 the prefabricated abutment (D6056x2) and the abutment supported porcelain/ 
ceramic crown (D6058x2) has been met. Therefore, we decided that the Plan has to pre-approve the 
prefabricated abutment (D6056x2) and the abutment supported porcelain/ceramic crown (D6058x2). 
 
We also decided that the Plan does not have to pre-approve the surgical placement of implant body 
(D6010x2). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 1, 2022. Therefore, 
we decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010x2). 
 
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.