Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the crowns (D2740) for tooth #28 and #29 and the core buildup 
(D2950) for tooth #29. We decided that the Plan does not have to pay for the core buildup (D2950) for tooth 
#28.  
 
You asked the Plan to pay for the crowns (D2740) and the core buildup (D2950) for tooth #28 and #29 
provided on March 31, 2023. You say that the dental services were necessary because there would be 
inevitably decay due to wear and tear on the teeth. The Plan says that clinical records did not show wear and 
tear and didn't support evidence of tooth decay; therefore, the dental services were not medically necessary. 
 
We decided that the Plan has to pay for the crowns (D2740) for tooth #28 and #29 and the core buildup 
(D2950) for tooth #29.  
 
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.  
 
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 pay for the crowns (D2740) for tooth #28 and #29 
and the core buildup (D2950) for tooth #29. Our reviewer says that the crowns (D2740) for tooth #28 and #29 
and the core buildup (D2950) for tooth #29 is medically necessary. Our physician reviewer found that the 
crown and core buildup is reasonable for tooth #29 as there is a lot of missing tooth structure, and to restore the 
tooth, both procedures are necessary. The buildup for this tooth is used to either restore the decay (if any) or the 
abfraction lesion). The crown is medically reasonable and necessary for tooth #28 as more than half of the 
enrollees tooth structure is missing.  
 
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 crowns (D2740) for tooth #28 and #29 and the core buildup (D2950) for 
tooth #29. have been met. Therefore, we decided that the Plan has to pay for the crowns (D2740) for tooth #28 
and #29 and the core buildup (D2950) for tooth #29.  
 
We also decided that the Plan does not have to pay for the core buildup (D2950) for tooth #28. 
 
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.  
 
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 pay for the core buildup (D2950) for tooth #28. Our 
reviewer says that the core buildup (D2950) for tooth #28 is not medically necessary. Our physician reviewer 
found that they are not able to determine whether the core buildup for tooth #28 is medically necessary as they 
see an existing filling, but there is no documentation as to whether this filling needs to be replaced with a 
buildup. Reasons for possible replacement includes decay, margins of existing filling are inadequate, or part of 
the filling material is fractured.  
 
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 core buildup (D2950) for tooth #28. have not been met. Therefore, we 
decided that the Plan does not have to pay for the core buildup (D2950) for tooth #28. 
  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.