Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the bone replacement graft (D7953) for tooth #18. We decided 
that the Plan does not have to pre-approve the sedation (D9239 and D9243).  
 You asked the Plan to pre-approve a bone replacement graft (D7953) and sedation (D9239 and D9243) for 
tooth #18.. You say that you have always had anxiety with the dentist, and you have had trauma with being 
conscious. The Plan says that the denial of the bone replace graft is correct because it is included with the 
extraction that was approved and the sedation is denied because you do not need 4 or more teeth taken out. 
 
We decided that the Plan has to pre-approve the bone replacement graft (D7953) for tooth #18.  
 
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 bone 
replacement grafts 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 service. Our reviewer says 
that the bone replacement graft for tooth #18 is medically. Our physician reviewer found that the 
documentation indicates that tooth #18 has been approved for a surgical extraction. This procedure involves 
removal of bone and or sectioning of the tooth. In order to maintain alveolar bone and to preserve the ridge it is 
medically reasonable to place a bone graft at the time of the extraction. In my opinion this is a separate 
procedure involving additional materials and meets 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 the bone replacement graft have been met. Therefore, we decided that the Plan 
has to pre-approve the bone replacement graft (D7953) for tooth #18.  
 
We also decided that the Plan does not have to pre-approve the sedation (D9239 and D9243). 
 
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 sedation 
when more than 4 teeth extracted or the need due to documented medical history. 
 
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 sedation (D9239 and D9243). Our 
reviewer says that the criteria for coverage for sedation was not met. Our physician reviewer found that there 
was no documentation indicating that due to the enrollee's medical history, IV sedation/analgesia was required 
for the removal of a single tooth.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plans rules for coverage of the sedation (D9239 and D9243) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the sedation (D9239 and D9243). 
 
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.