Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve crowns (D2751) for tooth #'s 5 and 13. We decided that the Plan 
does not have to pre-approve crowns (D2751) for tooth #'s 28 and 29.  
 
You asked the Plan to pre-approve crowns (D2751) for tooth #'s 5, 13, 28, and 29. You say that you would like 
to appeal the Plan's denial because the doctor deemed it necessary. The Plan says that there is enough of these 
teeth left to repair them with fillings. The Plan also says that there is no medical need for these crowns at this 
time. 
 We decided that the Plan has to pre-approve crowns (D2751) for tooth #'s 5 and 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 crowns 
(D2751) 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 crowns (D2751) for tooth #'s 5 and 13. 
Our reviewer says that tooth #'s 5 and 13 meet the criteria for coverage for crown restorations. Our physician 
reviewer found the documentation indicates that tooth #'s 5 and 13 appear to have large defective restorations. 
Our reviewer also found that restoring these with crowns 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 crowns (D2751) for tooth #'s 5 and 13 have been met. Therefore, we decided 
that the Plan has to pre-approve crowns (D2751) for tooth #'s 5 and 13.  
 
We also decided that the Plan does not have to pre-approve crowns (D2751) for tooth #'s 28 and 29. 
 
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 crowns 
(D2751) 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 crowns (D2751) for tooth #'s 28 and 29. 
Our reviewer says that tooth #'s 28 and 29 do not meet the criteria for coverage for crown restorations. Our 
physician reviewer found tooth #'s 28 and 29 appear to have adequate natural tooth structure making restoration 
with traditional filling material adequate. 
 
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 crowns (D2751) for tooth #'s 28 and 29 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve crowns (D2751) for tooth #'s 28 and 29. 
 
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.