Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #29 (D2750). We decided that the Plan does not 
have to pre-approve periodontal scaling and root planing (D4341, D4342) and bone grafts on tooth #8 and 9 
(D6104).  
 
You asked the Plan to pre-approve periodontal scaling, bone grafts, and a crown. You say that you disagree 
with the denial of dental services. The Plan denied your request. The Plan says that periodontal scaling is not 
medically necessary. The Plan also says that your benefit for crowns has been exhausted and bone grafts are 
not covered by your dental benefits. 
 
We decided that the Plan has to pre-approve a crown on tooth #29.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide documentation showing that the two crowns that were 
approved have been performed. Therefore, there is no evidence that your benefit for two crowns has been 
exhausted. We decided that the Plan has to pre-approve a crown on tooth #29 (D2750).  
 
We also decided that the Plan does not have to pre-approve periodontal scaling and bone grafts on tooth 
#8 and 9. 
 
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 periodontal 
scaling and root planing 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 periodontal scaling and root planing. 
Our reviewer says that the coverage criteria has not been met for periodontal scaling and root planing. Our 
physician reviewer found given there is no obvious loss of clinical attachment as evidenced by a lack of 
apparent bone loss there would be no diagnosis of a periodontal disease being present.  As there is no 
periodontal condition to treat, the requested periodontal scaling and root planing would not be medically 
necessary or 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 periodontal scaling have not been met. Though the Plan offers a dental benefit 
in excess of Medicare coverage, bone grafts are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) in the upper 
left quadrant, periodontal scaling and root planing (D4341) in the upper right quadrant, lower left quadrant, and 
lower right quadrant and bone graft on tooth #8 and 9 (D6104). 
 
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.