Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve crowns - porcelain tooth #'s 28 and 31 (D2751), and 
endodontic therapy, anterior tooth #'s 8 (D3310). We decided that the Plan does not have to pre-approve 
endodontic therapy, anterior tooth #10 (D3310).  
 
You asked the Plan to pre-approve crowns - porcelain tooth #'s 28 and 31 (D2751), and endodontic therapy, 
anterior tooth #'s 8 and 10 (D3310). The Plan says that this request is not medically necessary. 
 
We decided that the Plan has to pre-approve crowns - porcelain tooth #'s 28 and 31 (D2751), and 
endodontic therapy, anterior tooth #'s 8 (D3310).  
 
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 crowns and 
periodontal endodontic therapy 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 crowns - porcelain tooth #'s 28 and 31 
(D2751), and endodontic therapy, anterior tooth #'s 8 and 10 (D3310). Our reviewer says that the dental 
services are partially medically necessary. Our physician reviewer found tooth #8 has deep decay on the distal 
but is restorable and would be able to accept the requested endodontic treatment. Tooth #10 has extensive 
decay to the attachment on the distal aspect and would not be considered an acceptable candidate for 
endodontic treatment. Tooth #28 has a deep distal margin but it is restorable with a crown restoration. Tooth 
#31 has extensive restoration but it is restorable with a crown as the margins would be above the attachment 
level. The Plan allows for two crowns per arch and one root canal per tooth per lifetime. So long as the tooth is 
restorable, the Plan allows for two crowns per arch and endodontic treatment when necessary. Tooth #'s 28 and 
31 would be appropriate to receive crowns and #8 would be appropriately treated with endodontics. Tooth #10 
is not restorable and would not qualify for endodontic treatment. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of crowns - porcelain tooth #'s 28 and 31 (D2751), and endodontic therapy, 
anterior tooth # 8 (D3310) have been met. Therefore, we decided that the Plan has to pre-approve crowns - 
porcelain tooth #'s 28 and 31 (D2751), and endodontic therapy, anterior tooth #'s 8 (D3310).  
 
We also decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth #10 
(D3310). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plans rules for coverage of the endodontic therapy, anterior tooth #10  have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the endodontic therapy, anterior tooth #10. 
 
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.