Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #10. We decided that the Plan does not 
have to pre-approve a fixed partial denture (D6740), a retainer (D6245), core buildup (D2950), crowns 
(D2740) for tooth #6, #7, #8, #9, #10, #11.  
  You asked the Plan to pre-approve a fixed partial denture (D6740), a retainer (D6245), core buildup (D2950), 
crowns (D2740) for tooth #6, #7, #8, #9, #10, #11.. You say that the treatment provided was the correct and 
best treatment for the enrollee.  The Plan says that tooth #6 needs to be addressed with a successful root canal 
before a crown on this tooth can be considered. Tooth #8 could be restored with a traditional restoration. Tooth 
#9 could be restored with a traditional restoration. Tooth #10 appears to be hopeless and does not meet criteria 
for a crown. Tooth #11 appears to be healthy, therefore a crown for cosmetic purposes to match the other 
anterior teeth is not a covered service. 
 
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. The Plan covers the dental services when the 
services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says that a 
crown for tooth #10 would be reasonable and necessary. The crowns or a fixed bridge for teeth #6, #8, #9, and #11 
are not medically necessary as there is sufficient structure to allow for conventional restorations. Our physician 
reviewer found that that the treatment plan for a bridge is a possible alternate treatment plan after the removal 
of tooth #7, though not medically necessary. A removable appliance or implant could also be utilized to fill the 
missing space as alternatives. The only tooth that would qualify for a crown would be tooth #10 which has had 
endodontic treatment as well as a post and core. The tooth appears to have sufficient bone support and would a 
reasonable long-term prognosis. The radiographic appearance of tooth #10 appears to support a good 
prognosis. Teeth #6, #8, #9 and #11 do not have four or more involved surfaces along with 50% or more incisal 
damage and would therefore not qualify for a crown. 
 
In this instance tooth #7 would be able to be replaced with a removable appliance, and without any 
documentation to indicate a removable appliance could not be utilized, a fixed bridge would not be a covered 
service. 
 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #10.  
 
We also decided that the Plan does not have to pre-approve a fixed partial denture (D6740), a retainer 
(D6245), core buildup (D2950), crowns (D2740) for tooth #6, #7, #8, #9, #10, #11. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the 
Plan's rules for coverage of the dental services have partially been met. 
 
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.