Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 prefabricated abutments, 2 implant supported crowns, and 
pontic. We decided that the Plan does not have to pre-approve 1 additional prefabricated abutment, and 1 
additional implant supported crown.  
 
You asked the Plan to pre-approve the prefabricated abutments, implant supported crowns, and pontic. You say 
that the services are medically necessary. The Plan denied your request. The Plan says that the services are not 
medically necessary  
 
We decided that the Plan has to pre-approve 2 prefabricated abutments, 2 implant supported crowns, 
and pontic.  
 
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 
prefabricated abutments, implant supported crowns, and pontic 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 prefabricated abutments, implant 
supported crowns, and pontic. Our reviewer says that the dental services are medically necessary. Our 
physician reviewer found the documentation indicates that the area of teeth # 18, 19, and 20 is edentulous. The 
reviewer found that since the implant body (D6010) have been approved for area 18, 20 and 21, the rest of the 
treatment (implant abutments and implant crowns) are medically reasonable and necessary. The reviewer found 
that you have no masticatory function on the left side. The implant crowns would provide good bilateral 
mastication. Therefore, the reviewer found that the requested services are medically necessary. 
 
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 prefabricated abutments, implant supported crowns, and pontic have been 
met. Therefore, we decided that the Plan has to pre-approve 2 prefabricated abutments, 2 implant supported 
crowns, and pontic.  
 
We also decided that the Plan does not have to pre-approve 1 additional prefabricated abutment and 1 
additional implant supported crown. 
 
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 and the requested services are listed as 
covered, the frequency limits will be met with the decision in this case. The record shows that 2 prefabricated 
abutments are covered per year. The record also shows that 2 implant supported crowns are covered per year. 
Therefore, we decided that the Plan does not have to pre-approve 1 additional prefabricated abutment and 1 
additional implant supported crown. 
 
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.