Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the periodontal scalings and root planings (D4341) of the upper
right, upper left, lower right, and lower left quadrants. We decided that the Plan does not have to pre-approve
the drugs or medicaments dispensed in the office for home use (D9630).
You asked the Plan to pre-approve the periodontal scalings and root planings (D4341) of the upper right, upper
left, lower right, and lower left quadrants and drugs or medicaments dispensed in the office for home use
(D9630). You say that you would like these services to be reconsidered for coverage. The Plan says that the
medications requested for the procedure are not a covered service. The Plan also says that the records do not
indicate that there is significant bone loss (2.5+ mm from the cemento-enamel junction) and/or radiographic
root surface calculus on 4 or more teeth per quadrant that is required for coverage of the scalings and planings
under the enrollee's plan.
We decided that the Plan has to pre-approve the periodontal scalings and root planings (D4341) of the
upper right, upper left, lower right, and lower left quadrants.
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 periodontal
scalings and root planings (D4341) of the upper right, upper left, lower right, and lower left quadrants 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 periodontal scalings and root planings
(D4341) of the upper right, upper left, lower right, and lower left quadrants. Our reviewer says that the
documentation provided meets the criteria for coverage for periodontal scaling and root planing (D4341) in all
four quadrants. Our physician reviewer found the enrollee's dental record and radiographs indicate that 4mm to
5mm periodontal pockets exist in the four quadrants along with bleeding and subgingival calculus formation.
Our reviewer also found that periodontal scaling and root planing is medically reasonable and necessary to treat
the enrollee's periodontal disease and to prevent the condition from progressing to a more severe degree.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the periodontal scalings and root planings have been met. Therefore, we
decided that the Plan has to pre-approve the periodontal scalings and root planings (D4341) of the upper right,
upper left, lower right, and lower left quadrants.
We also decided that the Plan does not have to pre-approve the drugs or medicaments dispensed in the
office for home use (D9630).
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.
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. Therefore, we decided that the Plan does not have to pre-approve the
drugs or medicaments dispensed in the office for home use (D9630).
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.