Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve scaling and root planing of four or more teeth for the upper right, 
lower right, and lower left quadrants. We decided that the Plan does not have to pre-approve scaling and root 
planing of four or more teeth for the upper left quadrant.  You asked the Plan to pre-approve periodontal scaling and root planing of four or more teeth per quadrant 
(D4341) for all four quadrants. You say that these services are necessary and appropriate for this enrollee. The 
Plan says that these services are not necessary as fewer than four teeth are affected in each quadrant. 
 
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 periodontal 
scaling and root planing once per quadrant every three calendar years when the services are medically 
necessary and reasonable. 
 
We decided that the Plan has to pre-approve scaling and root planing of four or more teeth for the upper 
right, lower right and lower left quadrants.  
 
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 scaling and root planing of four or more 
teeth for the upper right, lower right and lower left quadrants. Our reviewer says that these services are 
medically necessary for these quadrants. Our physician reviewer found that based on the x-rays and periodontal 
charting for this enrollee, the requested services are medically necessary for the upper right, lower right and 
lower left quadrants. Without these procedures, the enrollee's periodontal health will decline, which will lead to 
pain, infection, and eventual loss of teeth. 
 
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 scaling and root planing of four or more teeth for the upper right, lower right 
and lower left quadrants have been met. Therefore, we decided that the Plan has to pre-approve scaling and 
root planing of four or more teeth for the upper right, lower right and lower left quadrants.  
 
We also decided that the Plan does not have to pre-approve scaling and root planing of four or more 
teeth for the upper left quadrant. 
 
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 scaling and root planing of four or more 
teeth for the upper left quadrant. Our reviewer says that the documentation provided is insufficient to support 
the medical necessity of the requested service for this quadrant. Our physician reviewer found that there are 
discrepancies noted in the clinical documentation for the upper left quadrant. From the clinical notes, the dental 
provider described the periodontal health of the enrollee- "coral pink, normal, scalloped, knife-edge, no 
calculus, no plaque, no bone defects, no bone loss," and stated "none" as the periodontitis status. The 
descriptors documented in the clinical note would apply to a person who is periodontally healthy, which is not 
the case for this enrollee. This information from the clinical notes is inconsistent with the periodontal charting 
and x-rays. There is also a discrepancy is the pocket depth recordings for the upper left quadrant. The 
periodontal chart records periodontal readings for tooth number 14 but the x-ray shows that tooth number 14 is 
too broken to record a pocket depth reading. Additional x-rays showing the bone level and corrected pocket 
depth readings for the upper left quadrant are required to support the medical necessity and to meet the Plans 
coverage criteria. 
 
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 periodontal scaling and root planing of four or more teeth for the upper left 
quadrant have not been met. Therefore, we decided that the Plan does not have to pre-approve scaling and root 
planing of four or more teeth for the upper left quadrant. 
 
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.