Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve four maxillary implants and two mandibular implants. We decided 
that the Plan does not have to pre-approve the additional maxillary implants and additional mandibular 
implants.  
 
You asked the Plan to pre-approve multiple endosteal implants (D6010) for the maxillary arch and mandibular 
arch. The Plan says that these implants are not medically necessary. The Plan also says that the x-rays and 
records do not show that there is not enough bone to keep a denture in the enrollee's mouth. 
 
We decided that the Plan has to pre-approve four maxillary implants and two mandibular implants.  
 
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 surgical 
placements of implant bodies: endosteal implants (D6010) 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 the endosteal implants (D6010). Our 
reviewer says that four maxillary implants and two mandibular are medically reasonable and necessary. Our 
physician reviewer found the edentulous maxillary and mandibular arches both with alveolar atrophy. Our 
reviewer found that it appears that due to the alveolar atrophy, retention and stabilization of a traditional 
denture would be marginal. The scope of the plan covers 4 maxillary and 2 mandibular implants. Our physician 
reviewer also found that this would be a reasonable and necessary approach to achieve adequate retention and 
stability of complete dentures.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of four maxillary implants and two mandibular implants have been met. Therefore, 
we decided that the Plan has to pre-approve four maxillary implants and two mandibular implants.  
 
We also decided that the Plan does not have to pre-approve the additional maxillary implants and 
additional mandibular implants. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum allowance for implants 
is four [4] implants on the maxillary arch and two [2] implants on the mandibular arch. The record shows that 
the enrollee has been approved to receive 4 implants on the maxillary arch and two implants on the mandibular 
arch, and the enrollee's implant benefit has been exhausted. Therefore, we decided that the Plan does not have 
to pre-approve the additional maxillary implants and additional mandibular implants. 
 
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.