Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing in four quadrants 
(D4341). We also decided that the Plan does not have to pre-approve the pontic - porcelain fused to high noble 
metal (D6240), and retainer crown - porcelain fused to high noble metal (D6750).  
 
You asked the Plan to pre-approve periodontal scaling and root planing - four or more teeth per quadrant 
(D4341), a pontic - porcelain fused to high noble metal (D6240), and retainer crown - porcelain fused to high 
noble metal (D6750). The Plan says that these services partially meet criteria for approval. 
 
We decided that the Plan has to pre-approve periodontal scaling and root planing in four quadrants 
(D4341).  
 
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 codes represented by D4341, 
D6240 and D6750. Our reviewer says that the documentation provided meets the criteria for periodontal 
scaling and root planing in four quadrants but does not meet the criteria for coverage for a fixed replacement 
bridge replacing tooth #19. Our physician reviewer found the documentation indicates the presence of 4-5mm 
periodontal pockets in all quadrants with areas of calculus accumulation and areas of bone loss. Periodontal 
scaling and root planing in four quadrants is medically reasonable and necessary to treat the patient's 
periodontal disease.  
 
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 dental codes represented by D4341 have been met. Therefore, we decided 
that the Plan has to pre-approve periodontal scaling and root planing in four quadrants (D4341).  
 
We also decided that the Plan does not have to pre-approve the pontic - porcelain fused to high noble 
metal (D6240), and retainer crown - porcelain fused to high noble metal (D6750). 
 
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 pontic - porcelain fused to high noble 
metal (D6240), and retainer crown - porcelain fused to high noble metal (D6750). Our reviewer says that the 
documentation provided does not meet the criteria for coverage for a fixed replacement bridge replacing tooth 
#19. Our physician reviewer found the fixed bridge in place appears adequate and no narrative was submitted 
indicating why a replacement bridge was needed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pontic - porcelain fused to high noble metal (D6240), and retainer crown - 
porcelain fused to high noble metal (D6750). have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the pontic - porcelain fused to high noble metal (D6240), and retainer crown - porcelain 
fused to high noble metal (D6750). 
 
 
 
 
 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.