Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a surgical placement of implant body: endosteal implant (D6010) 
and a custom fabricated abutment (D6057) for tooth #14. We decided that the Plan does not have to pre-
approve an abutment supported porcelain/ceramic crown (D6058) for tooth #14.  
 
You asked the Plan to pre-approve a surgical placement of implant body: endosteal implant (D6010), custom 
fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058) for tooth #14. The 
Plan says that the endosteal implant and custom fabricated abutment exceeds the benefit allowance. The Plan 
also says that an abutment supported porcelain/ceramic crown is allowed once per 84 months. 
 
We decided that the Plan has to pre-approve a surgical placement of implant body: endosteal implant 
(D6010) and a custom fabricated abutment (D6057) for tooth #14.  
 
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. Specifically, the Plan did not provide evidence showing one surgical placement 
of implant body: endosteal implant (D6010) and one custom fabricated abutment (D6057) have already been 
covered by the Plan. We asked for this information, but it was not provided to us. Without this information we 
cannot determine that the Plan's coverage rules support the denial of payment in this case. The record shows 
that the enrollee received endosteal implants (D6010) and custom fabricated abutment (D6057) on tooth #28 
and 29 on January 31, 2022, but the provided documentation does not support that an endosteal implant or a 
custom fabricated abutment was approved and covered for either tooth #28 or 29. Consequently, the Plan has 
not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pre-approve a 
surgical placement of implant body: endosteal implant (D6010) and a custom fabricated abutment (D6057) for 
tooth #14.  
 
We also decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic 
crown (D6058) for tooth #14. 
 
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, abutment supported porcelain/ceramic 
crown (D6058) is limited to one per 84 months. The record shows that you received an abutment supported 
porcelain/ceramic crown (D6058) on tooth #29 on January 31, 2022, and your abutment supported 
porcelain/ceramic crown (D6058) benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve an abutment supported porcelain/ceramic crown (D6058) for tooth #14. 
 
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.