Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve alveoloplasty in conjunction with extractions for teeth #3 and #4. 
We decided that the Plan does not have to pre-approve the implants, osseous surgery and biologic materials.  
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan says that biologic materials to aid in soft and osseous tissue regeneration is not covered by the Plan's 
dental benefit. The osseous surgery conflicts with the debridement and osseous contouring of a peri-implant 
defect, which has been approved, and the alveoloplasty is inclusive if you choose to extract these teeth, so 
approving this as a separate service is not medically necessary. The implants for teeth #3 and #4 are denied as 
there is a poor prognosis for this treatment. 
 
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 eligible dental 
services when they are medically necessary and reasonable. 
 
We decided that the Plan has to pre-approve alveoloplasty in conjunction with extractions for teeth #3 
and #4.  
 
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 alveoloplasty in conjunction with 
extractions for teeth #3 and #4. Our reviewer says that the criteria for coverage of this service are met. Our 
physician reviewer found that the requested alveoloplasty is reasonable and necessary in conjunction with the 
extraction of these teeth due to the severe bone loss in this area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of alveoloplasty in conjunction with extractions for teeth #3 and #4 have been met. 
Therefore, we decided that the Plan has to pre-approve alveoloplasty in conjunction with extractions for teeth 
#3 and #4.  
 
We also decided that the Plan does not have to pre-approve the implants, osseous surgery and biologic 
materials. 
 
Though the Plan offers a benefit in excess of Medicare coverage, the requested biologic materials to aid in soft 
and osseous tissue regeneration is not among the items/services covered under this benefit.  
 
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 implants and osseous surgery. Our 
reviewer says that the criteria for coverage of these services are not met. Our physician reviewer found that due 
to a lack of adequate bone in the area of teeth #3 and #4, the prognosis of successful bone integration of the 
implant bodies in this area appears poor, along with the enrollee's history of periodontal and peri-implant 
disease. The documentation also shows that treatment of the peri-implant disease in the lower left and right 
quadrants (D6102) was requested and approved by the Plan. The osseous surgery in this area would be 
supplanted by this treatment, and therefore is not medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the implants and osseous surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the implants, osseous surgery and biologic materials. 
 
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.