Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266), an immediate 
maxillary denture (D5130), an unspecified removal prosthodontic procedure (D5899), an implant supported 
removable denture (D6053), surgical removal of an implant (D6100), semi-precision attachments (D6192), application of blood concentrate (D7921), bone replacement grafts (D7953), fixed partial denture sectioning 
(D9120), and prefabricated abutments on tooth #6 and 11 (D6056). 
 
You asked the Plan to pre-approve the dental services. You say that the dental office needs to remove the 
existing implant because it is causing discomfort. The Plan denied your request. The Plan says the 
prefabricated abutments and denture sectioning are not medically necessary. The Plan also says that dental 
code D6053 is not valid. The Plan also says that the surgical removal of an implant (D6100), semi-precision 
attachments (D6192), application of blood concentrate (D7921), and bone replacement grafts (D7953) are not 
covered by your dental benefits. 
 
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 the dental 
services 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 dental services. Our reviewer says 
that the coverage criteria has not been met for fixed partial denture sectioning and prefabricated abutments on 
tooth #6 and 11. Our physician reviewer found that a review of the documentation indicates the failure of the 
existing implants due to severe bone loss. The integration of new implants in these areas appears to be unlikely. 
 
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 partial denture sectioning and abutments have not been met. Without the 
approval of these services the request for guided tissue regeneration (D4266), an immediate maxillary denture 
(D5130), and an unspecified removal prosthodontic procedure (D5899) was not approved. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the surgical removal of an implant 
(D6100), semi-precision attachments (D6192), application of blood concentrate (D7921), and bone 
replacement grafts (D7953) are not among those covered under this benefit.    
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find code D6053 is not an existing procedure code and is not valid for Medicare purposes. Therefore, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pre-approve guided tissue regeneration (D4266), an immediate maxillary denture (D5130), an unspecified 
removal prosthodontic procedure (D5899), an implant supported removable denture (D6053), surgical removal 
of an implant (D6100), semi-precision attachments (D6192), application of blood concentrate (D7921), bone 
replacement grafts (D7953), fixed partial denture sectioning (D9120), and prefabricated abutments on tooth #6 
and 11 (D6056).