Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown, porcelain fused to high 
noble alloys (D6066) for teeth numbers 19 and 20, an implant supported retainer for porcelain fused metal 
(D6076) for teeth numbers 12 and 14, a pontic, porcelain fused to high noble metal (D6240) for tooth number 
13, and custom fabricated abutment, including placement (D6057) for teeth numbers 12 and 14. 
 
  You asked the Plan to pre-approve an implant supported crown, porcelain fused to high noble alloys (D6066) 
for teeth numbers 19 and 20, an implant supported retainer for porcelain fused metal (D6076) for teeth numbers 
12 and 14, a pontic, porcelain fused to high noble metal (D6240) for tooth number 13, and custom fabricated 
abutment, including placement (D6057) for teeth numbers 12 and 14. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says for this service to be approved, you must have 
at least eight permanent back teeth that bite together. The Plan also says the records that were sent in show you 
have less than this amount. The Plan also says that the use of implants allowable under this plan may not give 
you the best tooth replacement option for your oral health 
 
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 an implant 
supported crown, porcelain fused to high noble alloys (D6066) for teeth numbers 19 and 20, an implant 
supported retainer for porcelain fused metal (D6076) for teeth numbers 12 and 14, a pontic, porcelain fused to 
high noble metal (D6240) for tooth number 13, and custom fabricated abutment, including placement (D6057) 
for teeth numbers 12 and 14 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 an implant supported crown, porcelain 
fused to high noble alloys (D6066) for teeth numbers 19 and 20, an implant supported retainer for porcelain 
fused metal (D6076) for teeth numbers 12 and 14, a pontic, porcelain fused to high noble metal (D6240) for 
tooth number 13, and custom fabricated abutment, including placement (D6057) for teeth numbers 12 and 14. 
Our reviewer says that you do not meet the criteria for the requested services. Our physician reviewer found 
there is not enough clinical information to determine whether the restorations of these implants are medically 
necessary, because implant restorations cannot be placed on implants that are not stable in the bone. Our 
physician reviewer also found that based on the limited information submitted, an implant supported crown, 
porcelain fused to high noble alloys (D6066) for teeth numbers 19 and 20, an implant supported retainer for 
porcelain fused metal (D6076) for teeth numbers 12 and 14, and custom fabricated abutment, including 
placement (D6057) for teeth numbers 12 and 14 are not medically necessary. 
 
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 an implant supported crown, porcelain fused to high noble alloys (D6066) for 
teeth numbers 19 and 20, an implant supported retainer for porcelain fused metal (D6076) for teeth numbers 12 
and 14, a pontic, porcelain fused to high noble metal (D6240) for tooth number 13, and custom fabricated 
abutment, including placement (D6057) for teeth numbers 12 and 14 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an implant supported crown, porcelain fused to high noble alloys 
(D6066) for teeth numbers 19 and 20, an implant supported retainer for porcelain fused metal (D6076) for teeth 
numbers 12 and 14, a pontic, porcelain fused to high noble metal (D6240) for tooth number 13, and custom 
fabricated abutment, including placement (D6057) for teeth numbers 12 and 14.