Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the one retainer crown (D6740). We decided that the Plan does not 
have to pay for the two core buildups, including any pins when required (D2950 x2), two custom fabricated 
abutments (D6057 x2), implant supported retainer for ceramic fixed partial denture (D6075), and additional 
retainer crown (D6740).  
 
You asked the Plan to pay for the two core buildups, including any pins when required (D2950 x2), two custom 
fabricated abutments (D6057 x2), implant supported retainer for ceramic fixed partial denture (D6075), and 
two retainer crowns (D6740 x2). You say that you would like these services to be approved for coverage. The 
Plan says that these services are not covered. 
 
We decided that the Plan has to pay for the one retainer crown (D6740).  
 
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and 
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under 
your plan contract including applicable conditions and limitations and any other conditions associated with the 
use or receipt of the benefits. 
 
The record shows that you received two retainer crowns (D6740 x2) which were denied by the Plan for not 
being covered. The 2021 Evidence of Coverage states that crowns are limited to one procedure code per 
calendar year. The contract does not clearly list which types of crowns are covered, nor does the documentation 
show that you had already exhausted this benefit. You reasonably believed one of the retainer crowns (D6740) 
would be covered at the in-network benefit rate because crowns are listed as a covered service. Therefore, we 
decided that the Plan has to pay for the one retainer crown (D6740).  
 
We also decided that the Plan does not have to pay for the two core buildups, including any pins when 
required (D2950 x2), two custom fabricated abutments (D6057 x2), implant supported retainer for 
ceramic fixed partial denture (D6075), and additional retainer crown (D6740). 
 
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 requested items or services are not 
among those covered under this benefit. The contract says that you are limited to one crown per calendar year. 
We have told the Plan that they must pay for one of the two retainer crowns that was provided on June 17, 2021 
and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
two core buildups, including any pins when required (D2950 x2), two custom fabricated abutments (D6057 
x2), implant supported retainer for ceramic fixed partial denture (D6075), and additional retainer crown 
(D6740). 
 
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.