Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve D2740. We decided that the Plan does not have to pre-approve
D4341, D6245, D6740, D7953.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan says
that the tooth must have noticeable bone loss or hard substance buildup on the tooth root.
We decided that the Plan has to pre-approve D2740.
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 dental
services 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 for D2740. Our reviewer says that a crown restoration
for tooth #24 is medically reasonable, since a root canal is required, and there appears to be significant coronal
breakdown due to caries.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of D2740 have been met. Therefore, we decided that the Plan has to pre-approve
D2740.
We also decided that the Plan does not have to pre-approve D4341, D6245, D6740 and D7953.
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 dental
services 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 the rest of the dental services. Our reviewer says that
the requested remaining dental services are not medically reasonable or necessary. Our physician reviewer
found that bone replacement (D7953) does not appear to be medically necessary in area #9. A review of the
documentation was incomplete to determine if periodontal scaling and root planing meets the criteria for
coverage since there was no record of periodontal pocket measurements. A fixed bridge replacing missing teeth
#'s 9 and 10 does not meet the criteria for coverage. A fixed bridge is not covered in the anterior region if there
are missing posterior teeth. In this case there are missing posterior teeth bilaterally in the maxilla.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of D4341, D6245, D6740, D7953 have not been met. Therefore, we decided that
the Plan does not have to pre-approve D4341, D6245, D6740, 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.