Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (dental code D4263) and collection 
and application of autologous blood concentrate product (dental code D7921) for tooth #5 provided on January 
4, 2022. 
  You asked the Plan to pay for bone replacement graft and collection and application of autologous blood 
concentrate product. You say that the Plan told them the procedures were not dental in nature and they were 
medical, and it was medically necessary. The Plan denied your request. The Plan says the bone grafting and 
related procedures are not a covered medical benefit of your health plan. These services are considered dental 
procedures and you are only covered for dental services by a dentist or an oral surgeon for surgery of the jaw or 
related structures, setting fractures of the jaw of facial bones, extraction of teeth to prepare the jaw for radiation 
treatment of neoplastic disease or services that would be covered when provided by a medical provider. 
 
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 namely 
limited dental procedures to surgery of the jaw, extractions only for the purpose of radiation treatment for 
treatment of a neoplasm when the services are medically necessary and reasonable when provided by a medical 
provider.  
 
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 pay for bone replacement graft and collection and 
application of autologous blood concentrate product. Our reviewer says that the medical plan that was 
submitted for review does not allow for dental treatment beyond what Medicare allows, namely limited dental 
procedures to surgery of the jaw, extractions only for the purpose of radiation treatment for treatment of a 
neoplasm. In this instance the treatment would be for a dental issue, specifically removal of a broken tooth and 
preparation of the site for a bone graft to support a dental implant. The coverage documentation provided was 
for medical only, though there were references to a dental plan that had denied the claim as being medical in 
nature. Based on the medical plan only as provided for the review, the Plan's criteria for dental procedures have 
not been met.  If there is a dental plan involved, this should be evaluated for its coverage issues. 
 
Our physician reviewer found the removal of the broken tooth and preparation for a bone graft is medically 
reasonable and necessary.  The removal of a tooth will induce loss of alveolar bone, and a graft placement at 
the time of extraction can preserve a significant amount of the bone in the area. Ridge preservation for future 
implant placement is commonly performed at the time of extraction.  This is a procedure focused on dental 
issues and not medical issues. 
 
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 bone replacement graft and collection and application of autologous blood 
concentrate product have not been met. Therefore, we decided that the Plan does not have to pay for bone 
replacement graft (dental code D4263) and collection and application of autologous blood concentrate product 
(dental code D7921) for tooth #5 provided on January 4, 2022.