Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of the lower right, 
upper right, and lower left quadrants, retainer crowns (D6740) for tooth #s 12 and 14, and a pontic (D6245) 
for tooth #13. We decided that the Plan does not have to pre-approve the drugs or medicaments (D9630).  
 
You asked the Plan to pre-approve the periodontal scalings and root planings (D4341) of the lower right, upper 
right, and lower left quadrants, retainer crowns (D6740) for tooth #s 12 and 14, pontic (D6245) for tooth #13, 
and drugs or medicaments (D9630). You say that the enrollee's periodontal disease will continue to get worse 
without these treatments. The Plan says that the teeth do not have noticeable bone loss or show on an x-ray that 
there is a hard substance built up on the root of the tooth. 
 
We decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of the lower 
right, upper right, and lower left quadrants, retainer crowns (D6740) for tooth #s 12 and 14, and a 
pontic (D6245) for tooth #13.  
 
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 
periodontal scalings and root planings (D4341) of the lower right, upper right, and lower left quadrants, retainer 
crowns (D6740) for tooth #s 12 and 14, and pontic for tooth #13 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 periodontal scalings and root 
planings (D4341) of the lower right, upper right, and lower left quadrants, retainer crowns (D6740) for tooth 
#s 12 and 14, and pontic for tooth #13. Our reviewer says that the documentation provided meets the criteria 
of medically necessity for scaling and root planings (D4341) and a replacement bridge for tooth #'s 12, 13, and 
14 (D6740, D6245). Our physician reviewer found the documentation indicates periodontal pockets of 4-5mm 
in all quadrants, subgingival calculus, and areas of bone loss. Periodontal scaling and root planing is medically 
reasonable and necessary to treat the enrollee's periodontal disease. Our reviewer found that the current bridge 
that was in place replacing tooth #13 is no longer retentive and was placed 40 years ago. Our physician 
reviewer also found that a replacement bridge to replace tooth #13 with a pontic (D6245) and restore tooth #'s 
12 and 14 with crown restorations (D6740) is medically reasonable and necessary. 
 
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 periodontal scaling and root planings (D4341) of the lower right, upper 
right, and lower left quadrants, retainer crowns (D6740) for tooth #s 12 and 14, and pontic for tooth #13 have 
been met. Therefore, we decided that the Plan has to pre-approve periodontal scalings and root planings 
(D4341) of the lower right, upper right, and lower left quadrants, retainer crowns (D6740) for tooth #s 12 and 
14, and a pontic (D6245) for tooth #13.  
 
We also decided that the Plan does not have to pre-approve the drugs or medicaments (D9630). 
 
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 
drugs or medicaments (D9630). 
 
  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.