Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the crowns (D2752) for tooth #'s 15 and 18. We decided that the
Plan does not have to pre-approve the endodontic therapy (D3330) for tooth #'s 18, 31, and 32, endodontic
therapy (D3320) for tooth #29, retainer crowns (D6750) for tooth #'s 29, 31, and 32, and a pontic (D6240) for
tooth #30.
You asked the Plan to pre-approve crowns (D2752) for tooth #'s 15 and 18, endodontic therapy (D3330) for
tooth #'s 18, 31, and 32, endodontic therapy (D3320) for tooth #29, retainer crowns (D6750) for tooth #'s 29,
31, and 32, and a pontic (D6240) for tooth #30. The Plan says that these services are not medically necessary.
We decided that the Plan has to pre-approve the crowns (D2752) for tooth #'s 15 and 18.
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 the crowns
(D2752) for tooth #'s 15 and 18 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 crowns (D2752) for tooth #'s 15 and
18. Our reviewer says that the documentation meets the criteria for coverage for crowns for tooth #'s 15 and 18.
Our physician reviewer found due to the breakdown and restoration in tooth #18 and defective crown on tooth
#15, crown restorations to provide adequate function are medically reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crowns (D2752) for tooth #'s 15 and 18 have been met. Therefore, we
decided that the Plan has to pre-approve the crowns (D2752) for tooth #'s 15 and 18.
We also decided that the Plan does not have to pre-approve the endodontic therapy (D3330) for tooth #'s
18, 31, and 32, endodontic therapy (D3320) for tooth #29, retainer crowns (D6750) for tooth #'s 29, 31,
and 32, and a pontic (D6240) for tooth #30.
Explanation of decision
We decided that the Plan has to pre-approve the crowns (D2752) for tooth #'s 15 and 18. We decided that the
Plan does not have to pre-approve the endodontic therapy (D3330) for tooth #'s 18, 31, and 32, endodontic
therapy (D3320) for tooth #29, retainer crowns (D6750) for tooth #'s 29, 31, and 32, and a pontic (D6240) for
tooth #30.
You asked the Plan to pre-approve crowns (D2752) for tooth #'s 15 and 18, endodontic therapy (D3330) for
tooth #'s 18, 31, and 32, endodontic therapy (D3320) for tooth #29, retainer crowns (D6750) for tooth #'s 29,
31, and 32, and a pontic (D6240) for tooth #30. The Plan says that these services are not medically necessary.
We decided that the Plan has to pre-approve the crowns (D2752) for tooth #'s 15 and 18.
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 the crowns
(D2752) for tooth #'s 15 and 18 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 crowns (D2752) for tooth #'s 15 and
18. Our reviewer says that the documentation meets the criteria for coverage for crowns for tooth #'s 15 and 18.
Our physician reviewer found due to the breakdown and restoration in tooth #18 and defective crown on tooth
#15, crown restorations to provide adequate function are medically reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crowns (D2752) for tooth #'s 15 and 18 have been met. Therefore, we
decided that the Plan has to pre-approve the crowns (D2752) for tooth #'s 15 and 18.
We also decided that the Plan does not have to pre-approve the endodontic therapy (D3330) for tooth #'s
18, 31, and 32, endodontic therapy (D3320) for tooth #29, retainer crowns (D6750) for tooth #'s 29, 31,
and 32, and a pontic (D6240) for tooth #30.
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 the
endodontic therapy (D3330) for tooth #'s 18, 31, and 32, endodontic therapy (D3320) for tooth #29, retainer
crowns (D6750) for tooth #'s 29, 31, and 32, and a pontic (D6240) for tooth #30 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 endodontic therapy (D3330) for
tooth #'s 18, 31, and 32, endodontic therapy (D3320) for tooth #29, retainer crowns (D6750) for tooth #'s 29,
31, and 32, and a pontic (D6240) for tooth #30. Our reviewer says that the documentation does not meet the
criteria for coverage for a root canal treatment for tooth #29 (D3320) and tooth #'s 18, 31 and 32 (D3330), and
a fixed bridge to replace missing tooth #30 is not a covered expense per the insurance plan. Our physician
reviewer found the documentation does not show that a root canal is necessary for tooth #18. Tooth #'s 29, 31,
and 32 do not appear to be restorable, and therefore root canal treatment is not medically reasonable. Our
reviewer also found that a fixed bridge is not a covered expense when multiple posterior teeth are missing.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the endodontic therapy (D3330) for tooth #'s 18, 31, and 32, endodontic therapy
(D3320) for tooth #29, retainer crowns (D6750) for tooth #'s 29, 31, and 32, and a pontic (D6240) for tooth #30
have not been met.
Therefore, we decided that the Plan does not have to pre-approve the endodontic therapy (D3330) for tooth #'s
18, 31, and 32, endodontic therapy (D3320) for tooth #29, retainer crowns (D6750) for tooth #'s 29, 31, and 32,
and a pontic (D6240) for tooth #30.
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.