Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain fused to high noble metal 
(D6750) Tooth #13 and 15, pontic - porcelain fused to noble metal (D6242) Tooth #14, diagnostic cast 
(D0470), intraoral - periapical each additional radiographic image (D0230) and intraoral - periapical first 
radiographic image (D0220). 
  You asked the Plan to pre-approve dental services. You say that you need the services and your $2,000 annual 
maximum should be applied toward services. The Plan denied your request. The Plan says they reprocessed 
D6750 Tooth #13 and 15 as retainer crown - porcelain fused to noble metal (D6752) Tooth #13 and retainer 
crown - full cast high noble metal (D6790) Tooth #15. Also, D6242 was reprocessed as pontic - cast noble 
metal (D6212) Tooth #14. 
 
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. Diagnostic cast (D0470) is not 
covered under the Plans dental benefits. Intraoral - periapical each additional radiographic image (D0230) is 
covered but is limited to one procedure code per calendar year and retainer crown - full cast high noble metal 
(D6790) is covered but is limited to one procedure code every five-calendar year. 
 
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 dental services. Our physician reviewer 
stated per the EOC, For dental conditions that have two or more possible treatments, the Plan will cover the 
lowest cost treatment, as long as it is proven to provide satisfactory results. If you choose to receive a higher 
cost treatment, you will be responsible to pay for the difference. Our physician reviewer found that the 
provided records in this case do not document that the health plans treatment has not been proven to provide 
satisfactory results. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0470 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve diagnostic 
cast (D0470). 
 
We looked at the file, the Plans rules, and Medicares rules. You have been pre-approved for intraoral - 
periapical first radiographic image (D0220) and retainer crown - porcelain fused to noble metal (D6752) Tooth 
#13. Therefore, these benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-
approve intraoral - periapical each additional radiographic image (D0230) and retainer crown - full cast high 
noble metal (D6790) Tooth #15. 
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve retainer crown - porcelain fused to high noble metal (D6750) Tooth #13 and 15, pontic - 
porcelain fused to noble metal (D6242) Tooth #14.