Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the simple extractions (D7140). We decided that the Plan does not 
have to pre-approve the endosteal implants (D6010).  
 
You asked the Plan to pre-approve the endosteal implants (D6010) and simple extractions (D7140). You say 
that the endosteal implants are medically necessary and reasonable for this enrollee's medical condition. The 
Plan says that endosteal implants are not a covered benefit under the enrollee's plan. The Plan also says that the 
extractions are not allowed because the enrollee's history record indicates tooth #'s 22 and 27 were previously 
extracted. 
 
We decided that the Plan has to pre-approve the simple extractions (D7140) for tooth #'s 22 and 27.  
 
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 simple 
extractions (D7140) 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 simple extractions (D7140) for tooth #'s 
22 and 27. Our reviewer says that the documentation provided meets the criteria for coverage for extractions 
(D7140) for tooth #'s 22 and 27. Our physician reviewer found the reason for the denial was that these teeth 
were previously extracted. The documentation provided (x-rays) indicate the presence of tooth #'s 22 and 27. 
Our reviewer found that these x-rays were not dated, and therefore cannot be verified that this information is up 
to date and the treatment is based on these x-rays. Our physician reviewer also found that based on the 
documentation provided, the teeth are present and meet the criteria for coverage. 
 
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 simple extractions (D7140) for tooth #'s 22 and 27 have been met. Therefore, 
we decided that the Plan has to pre-approve the simple extractions (D7140) for tooth #'s 22 and 27.  
 
We also decided that the Plan does not have to pre-approve the endosteal implants (D6010). 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
endosteal implants (D6010). 
 
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.