Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the removal of impacted tooth, soft tissue (D7220) for teeth #'s 1, 
16, removal of impacted tooth, partially bony (D7230) for tooth #s 17, 32. We decided that the Plan does not 
have to pre-approve the bone replacement graft for ridge preservation, per site (D7953)..  
 
You asked the Plan to pre-approve the alveoloplasty with extractions (D7311 x4), the removal of impacted 
tooth, soft tissue (D7220) for teeth #'s 1, 16, removal of impacted tooth, partially bony (D7230) for tooth #s 17, 
32, and the bone replacement graft for ridge preservation, per site (D7953). You say that are unable to sleep, 
experiences headaches, and jaw pain. The Plan says that the criteria is not met. 
 
We decided that the Plan has to pre-approve the removal of impacted tooth, soft tissue (D7220) for teeth 
#'s 1, 16, removal of impacted tooth, partially bony (D7230) for tooth #s 17, 32.  
 
The Plan rules say you must have bone that is sticking out in your gums that is causing pain and soreness. 
 
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 removal of impacted tooth, soft 
tissue (D7220) for teeth #'s 1, 16, removal of impacted tooth, partially bony (D7230) for tooth #s 17, 32. Our 
reviewer says that the services are medically necessary. Our physician reviewer found that the removal of teeth 
#'s 1, 16, 17 and 32 meet the criteria for coverage. The record shows that teeth #'s 17 and 32 are partially bony 
impacted and procedure code (D7230) is allowable.  
 
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 removal of impacted tooth, soft tissue (D7220) for teeth #'s 1, 16, removal 
of impacted tooth, partially bony (D7230) for tooth #s 17, 32 have been met. Therefore, we decided that the 
Plan has to pre-approve the removal of impacted tooth, soft tissue (D7220) for teeth #'s 1, 16, removal of 
impacted tooth, partially bony (D7230) for tooth #s 17, 32.  
 
We also decided that the Plan does not have to pre-approve the bone replacement graft for ridge 
preservation, per site (D7953). 
 
The Plan rules say you must have bone that is sticking out in your gums that is causing pain and soreness. 
 
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 bone replacement graft for ridge 
preservation, per site (D7953). Our reviewer says that there does not appear to be a medical need for bone 
replacement grafts at the extraction sites.  
 
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 bone replacement graft for ridge preservation, per site (D7953) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the bone replacement graft for 
ridge preservation, per site (D7953). 
 
 
 
 
 
 
 
 
 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.