Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve crowns for teeth #19 and #30. We decided that the Plan does not 
have to pre-approve crowns for teeth #6-#11.  
You asked the Plan to pre-approve crowns. You say that these services are necessary, as your teeth are 
disintegrating and not in good shape. The Plan says that these services are not medically necessary, as these 
teeth are not badly broken or in need of crown restorations. Permanent anterior teeth must have pathologic 
destruction to the tooth by caries or trauma, and must involve four or more surfaces and at least 50% of the 
incisal edge. The Plan also says that crowns for teeth #19 and #30 are excluded from coverage. 
 
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. The Plan covers crowns when 
they are medically necessary and reasonable. 
 
We decided that the Plan has to pre-approve crowns for teeth #19 and #30.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that crowns for teeth #19 and #30 are denied as they are not 
eligible for coverage under your dental Plan. The Plan cites the Office Reference Manual's rules. The Office 
Reference Manual was not provided to us for review, and therefore the exclusion rules for crowns on these 
teeth cannot be verified. Your contract with the Plan does not clearly state that crowns for these teeth are 
excluded from coverage, and the contract states that restorative services are covered by the Plan. The Plan's 
denial of crowns for teeth #19 and #30 are not substantiated in this case. 
 
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 for teeth #19 and #30. Our 
reviewer says that the crowns are medically reasonable and necessary in this case. Our physician reviewer 
found that teeth #19 and #30 have completed root canals and crown restorations on these teeth are reasonable 
and necessary to provide adequate masticatory function and prevent fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of crowns have been met. Therefore, we decided that the Plan has to pre-approve 
crowns for teeth #19 and #30.  
 
We also decided that the Plan does not have to pre-approve crowns for teeth #6-#11. 
 
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 for teeth #6-#11. Our reviewer 
says that the criteria for coverage of crowns are not met for these teeth. Our physician reviewer found that teeth 
#6-#11 do not exhibit significant coronal breakdown due to carries or fracture to warrant crown restoration. 
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
Medicare rules for coverage of crowns for teeth #6-#11 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve crowns for teeth #6-#11. 
 
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.