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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
The health plan contract says Criteria for Cast Crowns Documentation needed for review of procedure:-
Appropriate radiographs showing clearly the adjacent and opposing teeth should be submitted for review:
bitewings, periapicals or panorex.-Treatment rendered without necessary review will still require that sufficient
and appropriate radiographs showing clearly the adjacent and opposing teeth be submitted with the claim
for review for payment. Criteria-In general, criteria for crowns will be met only for permanent teeth needing
multi-surface restorations where other restorative materials have a poor prognosis.-Permanent molar teeth must
have pathologic destruction to the tooth by caries or trauma, and should involve four or more surfaces and two
or more cusps.-Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or trauma, and
should involve three or more surfaces and at least one cusp.-Permanent anterior teeth must have pathologic
destruction to the tooth by caries or trauma, and must involve four or more surfaces and at least 50% of the
incisal edge.A request for a crown following root canal therapy must meet the following criteria-Request
should include a dated post-endodontic radiograph.-Tooth should be filled sufficiently close to the
radiological apex to ensure that an apical seal is achieved, unless there is a curvature or calcification of the
canal that limits the ability to fill the canal to the apex.-The filling must be properly condensed/obturated.
Filling material does not extend excessively beyond the apex.
To meet criteria, a crown must be opposed by a tooth or denture in the opposite arch or be an abutment for a
partial denture.-The patient must be free from active and advanced periodontal disease.
The fee for crowns includes the temporary crown that is placed on the prepared tooth and worn while the
permanent crown is being fabricated for permanent teeth.-Cast Crowns on permanent teeth are expected to last,
at a minimum, five years. Approval for Crowns will not meet criteria if:-A more cost effective means of
restoration is possible that provides quality care and meets the standard of care means of restoration is
possible.-Tooth has subosseous and/or furcation caries.-Tooth has advanced periodontal disease.-Tooth is a
primary tooth.-Crowns are being planned to alter vertical dimension. You can find this information on pages
39-40 the plan's dental office reference manual.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.