Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve  a lower partial denture. We decided that the Plan does not have to 
pre-approve crowns, pontic - porcelain fused to noble metal, and retainer crown - porcelain fused to high noble 
metal.  
 
You asked the Plan to pre-approve crowns (D2740 x2), a lower partial denture (D5226), pontic - porcelain 
fused to noble metal (D6242 x7), and retainer crown - porcelain fused to high noble metal (D6750 x7). You say that the services are necessary. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
We decided that the Plan has to pre-approve  a lower partial denture.  
 
The Plan follows Medicare rules. Medicare rules say that Medicare will not pay for dental services. 
 
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 a lower partial denture. Our reviewer 
says that the services are medically necessary. Our physician reviewer found a mandibular removable appliance 
(D5226) meets the criteria for coverage.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lower partial denture have been met. Therefore, we decided that the Plan has 
to pre-approve  a lower partial denture.  
 
We also decided that the Plan does not have to pre-approve crowns, pontic - porcelain fused to noble 
metal, and retainer crown - porcelain fused to high noble metal. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare will not pay for dental services. 
 
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 crowns, pontic - porcelain fused to 
noble metal, and retainer crown - porcelain fused to high noble metal. Our reviewer says that the services are 
not medically necessary Our physician reviewer found it appears that two treatment plans have been submitted 
for replacement of the missing teeth in the lower arch (#'s 18, 19, 23-27, 29 and 30). One a fixed bridge and 
one a removable appliance. The fixed bridge does not meet the criteria for coverage since there are multiple 
missing posterior teeth in the arch. Therefore, treatment codes D6242 and D6750 do not meet the criteria for 
coverage.  Separate crowns (D2740) on teeth #'s 21 and 22 do not meet the criteria for coverage since they do 
not appear to have significant coronal breakdown due to caries or fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of crowns, pontic - porcelain fused to noble metal, and retainer crown - porcelain 
fused to high noble metal have not been met. Therefore, we decided that the Plan does not have to pre-approve 
crowns, pontic - porcelain fused to noble metal, and retainer crown - porcelain fused to high noble metal. 
 
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.