Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a CT scan (D0367). We decided that the Plan does not have to 
pre-approve an abutment supported porcelain (D6060) for tooth number 14, an implant placement (D6010) for 
tooth number 14, a prefabricated abutment (D6056) for tooth number 14, a bone replacement graft for ridge 
preservation (D7953) for tooth number 14, and sinus augmentation (D7951).  
 
You asked the Plan to pre-approve an abutment supported porcelain (D6060) for tooth number 14, an implant 
placement (D6010) for tooth number 14, a prefabricated abutment (D6056) for tooth number 14, a bone 
replacement graft for ridge preservation (D7953) for tooth number 14, sinus augmentation (D7951) and a CT 
scan (D0367). You say that you have tooth pain and cannot eat. You also say that you get severe headaches and 
cannot chew your food when it touches that tooth. The Plan says that the CT scan (D0367) is allowed one time 
every six months and you have used this benefit within the last six months. The Plan also says that an abutment 
supported porcelain (D6060), an implant placement (D6010), a prefabricated abutment (D6056), a bone 
replacement graft for ridge preservation (D7953), and sinus augmentation (D7951) are not covered benefits. 
 
We decided that the Plan has to pre-approve a CT scan (D0367).  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE).  
 
The file shows that the Plan failed to provide verification of the CT scan (D0367) that they say you already 
have received. Without the verification, we cannot verify that you had the CT scan within the past six months 
of this request. Therefore, we decided that the Plan has to pre-approve a CT scan (D0367).  
 
We also decided that the Plan does not have to pre-approve an abutment supported porcelain (D6060) 
for tooth number 14, an implant placement (D6010) for tooth number 14, a prefabricated abutment 
(D6056) for tooth number 14, a bone replacement graft for ridge preservation (D7953) for tooth number 
14, and sinus augmentation (D7951). 
 
The Plan rules say that any dental services not listed in the table of covered services in the Plans dental benefit 
limitations and exclusions guide are excluded from coverage.  
 
The file does not show that these requested services are a covered benefit. Therefore, we decided that the Plan 
does not have to pre-approve an abutment supported porcelain (D6060) for tooth number 14, an implant 
placement (D6010) for tooth number 14, a prefabricated abutment (D6056) for tooth number 14, a bone 
replacement graft for ridge preservation (D7953) for tooth number 14, and sinus augmentation (D7951). 
 
  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.