Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two core buildups, including any pins when required (D2950 x2) 
and one gingivectomy or gingivoplasty (D4211) for quadrant #3. We decided that the Plan does not have to 
pre-approve four restorative procedures (D2999 x4), two clinical crown lengthenings (D4249 x2), additional 
gingivectomy or gingivoplasty (D4211) for quadrant #3, one pontic (D6240), and two retainer crowns (D6750 
x2).  
 
You asked the Plan to pre-approve four restorative procedures (D2999 x4), two clinical crown lengthenings 
(D4249 x2), two core buildups, including any pins when required (D2950 x2), two gingivectomies or 
gingivoplasties (D4211 x2) for quadrant #3, one pontic (D6240), and two retainer crowns (D6750 x2). The 
Plan says that the unspecified restorative procedures and clinical crown lengthenings are not covered under 
your plan. The Plan says that the maximum benefits have been reached for the core buildups, pontics, and 
retainer crowns. The Plan also says that the gingivectomy or gingivoplasty is considered inclusive with another 
treatment being done. 
 
We decided that the Plan has to pre-approve two core buildups, including any pins when required 
(D2950 x2) and one gingivectomy or gingivoplasty (D4211) for quadrant #3.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and Medicare rules. The contract says that you are limited to 3 of codes D2950 to D2954 
every calendar year. The records provided do not show that you have exhausted this benefit. The Plan contract 
also says that you are limited to one of either codes D4210 or D4211 once per quadrant every 2 calendar years. 
The record does not show that you have already received a gingivectomy or gingivoplasty (D4211) in quadrant 
#3 over the last 2 years. Based on this information, we decided that the Plan's rules for coverage of two core 
buildups, including any pins when required (D2950 x2) and one gingivectomy or gingivoplasty (D4211) for 
quadrant #3 have been met. Therefore, we decided that the Plan has to pre-approve two core buildups, 
including any pins when required (D2950 x2) and one gingivectomy or gingivoplasty (D4211) for quadrant #3.  
 
We also decided that the Plan does not have to pre-approve four restorative procedures (D2999 x4), two 
clinical crown lengthenings (D4249 x2), additional gingivectomy or gingivoplasty (D4211) for quadrant 
#3, one pontic (D6240), and two retainer crowns (D6750 x2). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the unspecified restorative procedure 
(D2999) and clinical crown lengthening (D4249) are not among those covered under this benefit. The Plan 
contract says that you are limited to one of either codes D4210 or D4211 once per quadrant every 2 calendar 
years. The record shows that you have requested two gingivectomies or gingivoplasties (D4211 x2) for 
quadrant #3, one of which has been approved, and your gingivectomy or gingivoplasty (D4211) benefit for 
quadrant #3 has been exhausted. The contract says that you are limited to 3 of codes D2710 to D2792 and 
D6210 to D6792 every calendar year. The record shows that you were approved to receive retainer crowns 
(D6750) on tooth #'s 18, 20, and 21 and your limit of 3 of either codes D2710 to D2792 and D6210 to D6792 
has been exhausted. Therefore, we decided that the Plan does not have to pre-approve four restorative 
procedures (D2999 x4), two clinical crown lengthenings (D4249 x2), additional gingivectomy or gingivoplasty 
(D4211) for quadrant #3, one pontic (D6240), and two retainer crowns (D6750 x2). 
 
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.