Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (dental code D2980) for tooth #3 and a root 
canal (dental code D3310) for tooth #5 and #30. 
 
You asked the Plan to pre-approve a crown and root canal. You say that should be covered because your dental 
provider discussed other procedures. They said the enrollee can have an extraction and you do not want to have 
your teeth extracted and then get dentures. You would like your teeth saved. The Plan denied your request. The 
Plan says they denied the authorization because the Program Dental Guidelines will not cover these services. 
More specifically because the patient has or will have 8 points (4 top and 4 bottom natural or prosthetic teeth) 
in biting contact. Based on the review of the x-rays sent by the enrollee's dentist, our reviewer thinks that she 
has enough teeth in the back of her mouth that touch. This means our reviewer decided the enrollee has enough 
teeth that touch in the back of her mouth to chew her food without teeth #'s 3, 5, and 30. Because we believe 
she will have at least 8 teeth that touch when she bites down without teeth #'s 3, 5, and 30, she can reasonably 
extract these teeth. 
 
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 a crown and 
root canal 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 a crown and root canal. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found tooth #3 has had root canal 
treatment and appears to have a temporary crown placed on it.  Given the radiographic appearance of #3, it 
appears to be suitable for a crown restoration. Teeth #5 and #30 do not have documented support for the need 
for endodontic treatment as requested. Without clear radiographic evidence, documented symptoms from 
diagnostic testing should be available to support the need. In this instance there is insufficient support for the 
need for root canal treatments for #5 and #30, and insufficient support for the need for crowns on either tooth.  
Crowns are usually considered where more than 50% of the tooth structure has been damaged from decay or 
fracture. In this case the teeth in question do not have significant structural damage and would not require a 
crown. Posts are only used following root canal treatment, which has not been performed or approved for #5 or 
#30. 
 
The Plan provides that if there are eight or more contacts in the posterior present then placement of crowns, or 
performing root canal therapy, would not be considered necessary. In this case #3, #5 and #30 would not be 
necessary to maintain at least eight posterior contacts. Teeth # 4 and #29, #12 and #21, #13 and #20, #15 and 
#18 would contact even if #3, #5 and #30 were removed. Given the lack of impact on the basic eight posterior 
contact criteria, the plan's criteria for performing the additional procedures on #3, #5 or #30 would not meet the 
Plan criteria. 
 
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 root canal have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown (dental code D2980) for tooth #3 and a root canal (dental code D3310) 
for tooth #5 and #30.