Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown 
represented by current procedural terminology (CPT) code D6065, the surgical placement of an endosteal 
implant (D6010), a prefabricated abutment (D6056), 4 pontics (D6245), periodontal scaling and root planing in 
4 quadrants (D4341), and a crown (D2740) for tooth #7. 
 
You asked the Plan to pre-approve the dental services. You say that the services in dispute are necessary and a 
quick resolution is required because you need other dental work done. The Plan denied your request. The Plan 
says your benefits for the requested items and services have already been exhausted. 
 
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, certain limitations apply.  
 
The record shows that the Plan approved coverage for code D6065 for tooth #20 and tooth #30 in the 2022 
calendar year. This exhausted your benefit for coverage of this code in the 2022 calendar year, and the request 
for coverage of code D6065 for tooth #5 exceeds the benefit limitation.  
 
The record shows that the Plan approved coverage for code D6010 for tooth #20 and tooth #30 in the 2022 
calendar year. This exhausted your benefit for coverage of this code in the 2022 calendar year, and the request 
for coverage of code D6010 for tooth #5 exceeds the benefit limitation. 
 
The record shows that the Plan approved coverage for code D6056 for tooth #20 and tooth #30 in the 2022 
calendar year. This exhausted your benefit for coverage of this code in the 2022 calendar year, and the request 
for coverage of code D6056 for tooth #5 exceeds the benefit limitation.  
 
The record shows that the Plan approved coverage for code D6245 for 3 of the 7 teeth you requested coverage 
of. This exhausts your benefit for coverage of this code in 2022 calendar year, and the request for coverage of 4 
additional pontics beyond the 3 approved exceeds the benefit limitation.  
 
The record shows that the Plan approved coverage for code D4341 of quadrants 20 and 30 for treatment 
received on March 30, 2022. The record shows that the Plan approved coverage for code D4341 of quadrants 
10 and 40 for treatment on April 13, 2022. This exhausts your benefit for coverage of this code for 2 calendar 
years from the dates of service, and the request for coverage of additional periodontal scaling and root planing 
exceeds the benefit limitations. 
 
The record shows that the Plan paid for code D2740 for treatment to tooth #7 on June 13, 2022. This exhausts 
your benefit for coverage of this code on the same tooth for 5 calendar years, and the request for another crown 
on tooth #7 currently exceeds the benefit limitations. 
 
 
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic 
crown represented by current procedural terminology (CPT) code D6065, the surgical placement of an 
endosteal implant (D6010), a prefabricated abutment (D6056), 4 pontics (D6245), periodontal scaling and root 
planing in 4 quadrants (D4341), and a crown (D2740) for tooth #7.