Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth #6 and
extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of
mucoperiosteal flap if indicated (D7210) for teeth #7, 8, 9, and 10.
You asked the Plan to pre-approve a crown and tooth extractions. You say that these services are medically
necessary. The Plan denied your request. The Plan says x-ray images show little decay on tooth 6, which can be
restore with a conventional filling and the enrollee's teeth can be removed with simpler extractions.
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 crowns and
tooth extractions when the services are medically necessary and meet the Plan's coverage criteria detailed in
the Medicare Rules section of this letter.
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 a crown and tooth extractions. Our
reviewer says that the crown for tooth 6 and the surgical extractions for teeth 7-10 are not medically necessary.
Our physician reviewer found that the provided information does not indicate any extensive structural damage
to tooth #6 that would require a full coverage crown. The tooth appears to be rotated in the arch and have
possibly a small carious lesion. It does not appear that it would be reasonable or necessary to place a crown on
tooth #6. From the provided x-rays it appears that any small carious lesion can be restored with a conventional
composite restoration.
The surgical extractions do not appear to be medically necessary. There is available coronal structure on each
of the noted teeth, although there is noted breakdown of structure as well. There appears to be sufficient
remaining coronal structure such that a surgical extraction would not be anticipated at the outset. From the
provided information it does not appear that removal of bone would be necessary to remove any of the noted
teeth. There is remaining coronal structure on each of the teeth and the proximal positions of the teeth to be
removed allows for easier elevation and luxation of the teeth upon extraction. From the provided information it
would not be anticipated that surgical extraction would be needed. Teeth 7-10 are single rooted teeth with some
clinical crown visible in the mouth, though there is some noted breakdown of the teeth.
The enrollee does not appear to meet the Plan's criteria for the requested services at this time. Tooth #6 does
not appear to have significant breakdown of structure such that a full coverage crown would be required. Teeth
7-10 do not appear to require surgical removal as requested.
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 a crown and tooth extractions have not been met. Therefore, we decided that the
Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth #6 and extractions, erupted
tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if
indicated (D7210) for teeth #7, 8, 9, and 10.