Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the office visit, x-ray of the facial bones, x-ray of the skull. We decided
that the Plan does not have to pay for x-ray of the sinuses.
You asked the Plan to pay for the office visit, x-ray of the facial bones, x-ray of the skull. You say that these
services were medically necessary and not dental in nature. The Plan says that the requested services were not
medically necessary as they are considered dental.
We decided that the Plan has to pay for the office visit, x-ray of the facial bones, x-ray of the skull.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and
necessary.
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 the office visit, x-ray of the facial bones, x-ray
of the skull. Our reviewer says that these services were medically reasonable and necessary. Our physician
reviewer found that the documentation does support that the services would be to treat a medical condition and
not services to treat the teeth or supporting services. The examination would appear to be reasonable and
necessary as it was requested by the patient's Otolaryngologists specialist. The x-rays of the skull and facial
bones would have been appropriate as the TM joints would have needed imaging to evaluate position and
function.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the office visit, x-ray of the facial bones, x-ray of the skull have been met.
Therefore, we decided that the Plan has to pay for the office visit, x-ray of the facial bones, x-ray of the skull.
We also decided that the Plan does not have to pay for x-ray of the sinuses.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and
necessary.
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 x-ray of the sinuses. Our reviewer says that
the x-ray of the sinus was not medically necessary. Our physician reviewer found that the x-ray of the paranasal
sinuses appears to beyond the scope of the provider's needs as the patient had been seen by an ENT specialist
previously who would have evaluated the sinus as that specialty would have indicated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of x-ray of the sinuses have not been met. Therefore, we decided that the Plan does
not have to pay for x-ray of the sinuses.
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.