Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pre-approve periodontal scaling and root planing. We decided that the Plan does not have to pre-approve pontic - porcelain fused to predominantly base metal (D6241) and retainer crown - porcelain fused to predominantly base metal (D6751) for a bridge.   You asked the Plan to pre-approve periodontal scaling and root planing. You say that the enrollee has early periodontitis and to prevent the disease to progress needs scaling and root planing to be done on lower arch. The Plan says that periodontal scaling and root planing is not medically necessary, and bridges are not covered services.  We decided that the Plan has to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341) for the lower right and lower left quadrants.   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 rules say that periodontal scaling and root planning is covered when there are four or more teeth in the quadrant, 5 mm or more pocketing on 2 or more teeth indicated on the perio charting and presence of root surface calculus and/or noticeable loss of bone support on x-rays.  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 periodontal scaling and root planing. Our reviewer says that periodontal scaling and root planing is medically necessary and reasonable. Our physician reviewer found that a review of your dental record and radiographs indicate the presence of four or more teeth per quadrant, multiple areas of 4-5mm pockets and bleeding in multiple areas. Therefore, the periodontal scaling and root planing is medically reasonable and necessary to treat the periodontal condition of the enrollee.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of periodontal scaling and root planing have been met. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341) for the lower right and lower left quadrants.   We also decided that the Plan does not have to pre-approve pontic - porcelain fused to predominantly base metal (D6241) and retainer crown - porcelain fused to predominantly base metal (D6751) for a bridge.  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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the pontic and retainer crown for a bridge are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve pontic - porcelain fused to predominantly base metal (D6241) and retainer crown - porcelain fused to predominantly base metal (D6751) for a bridge.       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.