Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the surgical extractions. We decided that the Plan does not have 
to pre-approve the alveoplasty (D7310 and D7311), and the removal of torus manibularis (D7473).  
 
You asked the Plan to pre-approve the surgical extractions (D7210) for tooth #2, #6, #7, #8, #9, #10, #11, #12, 
#13, #14, #15, #27, #28, and #29, the alveoplasty (D7310 and D7311), and the removal of torus manibularis 
(D7473).. You say that you have provided the necessary radiographs for the requested services to be approved. 
The Plan says that the records and x-rays do not show the need for bone removal or sectioning of these teeth to 
surgically extract them. Your benefit for the alveoplasty has already been exhausted. Also, the removal of torus 
manibularis is not covered by the Plan. 
 
We decided that the Plan has to pre-approve the surgical extractions.  
 
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 surgical 
extractions (D7210) when the services are medically necessary and reasonable. 
 
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 surgical extractions (D7210) for tooth 
#2, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #27, #28, and #29. Our reviewer says that the surgical 
extractions are medically necessary and reasonable. Our physician reviewer found that the enrollee has decay 
that may require a more extensive extraction procedure. The panoramic x-ray was reviewed. To assess 
horizontal bone level, bitewing x-rays are usually taken and assessed as they give the most accurate 
representation. The plan is stating denial for coverage of the surgical extractions stating that there is moderate 
to severe bone loss around the teeth, and therefore these procedures are not necessary. From the panoramic 
image, I see that the teeth that are severely decayed, and when teeth are severely decayed, it is difficult to use 
forceps to remove the whole tooth as the tooth will break.  
 
In this scenario, a surgical extraction (D7210) is performed for teeth with severe decay. A panoramic x-ray is 
good for assessing anatomical structures, but it is not the standard of care to use them to diagnose decay or 
bone levels. Bitewing radiographs are normally used to diagnose decay and bone levels. If a cavity is seen on a 
panoramic x-ray, it means the decay is very large.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical extractions (D7210) for tooth #2, #6, #7, #8, #9, #10, #11, #12, #13, 
#14, #15, #27, #28, and #29 have been met. Therefore, we decided that the Plan has to pre-approve the surgical 
extractions.  
 
We also decided that the Plan does not have to pre-approve the alveoplasty (D7310 and D7311), and the 
removal of torus manibularis (D7473). 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved the alveoplasty (D7310) and a buccal/labial frenectomy (D7961) on June 27, 
2023; therefore, your benefit for the alveoplasty (D7310) was exhausted on the date of approval of June 27, 
2023. The removal of torus manibularis is not covered under the Plans dental benefit. Therefore, we decided 
that the Plan does not have to pre-approve the alveoplasty (D7310 and D7311), and the removal of torus 
manibularis (D7473). 
 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.