Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the removal of residual tooth roots for tooth #14. We decided that
the Plan does not have to pre-approve the removals of residual tooth roots for tooth #'s 11 and 12.
You asked the Plan to pre-approve removals of residual tooth roots (D7250) for tooth #'s 11, 12, and 14. The
Plan says that the x-rays do not support the code requested.
We decided that the Plan has to pre-approve the removal of residual tooth roots (D7250) 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 Plan's coverage rules apply in this case. The Plan covers the removal
of residual tooth roots for tooth #14 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 removal of residual tooth roots for
tooth #14. Our reviewer says that the criteria appears to be met for the removal of the residual roots of tooth
#14. Our physician reviewer found there does appear to be residual roots in the area of tooth #14 which appear
to require a cutting procedure for removal.
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 removal of residual tooth roots for tooth #14 have been met. Therefore, we
decided that the Plan has to pre-approve the removal of residual tooth roots (D7250) for tootth #14
We also decided that the Plan does not have to pre-approve the removals of residual tooth roots (D7250)
for tooth #'s 11 and 12.
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 the removals
of residual tooth roots for tooth #'s 11 and 12 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 removals of residual tooth roots for
tooth #'s 11 and 12. Our reviewer says that the documentation provided does not meet the criteria for coverage
for residual root removal via cutting procedure (D7250) for #'s 11 and 12. Our physician reviewer found the
review of the enrollee's record and x-rays indicate that there does not appear to be residual roots #'s 11 and 12
present.
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 removals of residual tooth roots for tooth #'s 11 and 12 have not been met.
Therefore, we decided that the Plan does not have to pre-approve the removals of residual tooth roots (D7250)
for tooth #'s 11 and 12.
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