Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve surgical placement of implant body: endosteal implant 
(D6010) and prefabricated abutment  includes modification and placement (D6056) Tooth #21, 23, 26. 
We decided that the Plan does not have to pre-approve implant /abutment supported removable denture for 
edentulous arch - mandibular (D6111).  
 
You asked the Plan to pre-approve D6010, D6056 Tooth #21, 23, 26 and 28, and D6111. You say that the 
requested services are medically necessary for the enrollee. The Plan says that D6010 and D6056 do not meet 
criteria. 
 
We decided that the Plan has to pre-approve surgical placement of implant body: endosteal implant 
(D6010), prefabricated abutment  includes modification and placement (D6056) Tooth #21, 23, 26.  
 
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 has to pre-approve 
D6010 and D6056 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 dental services. Our physician reviewer 
found the documentation provided meets the criteria for coverage for implant body (D6010) and implant 
abutment (D6056). A review of the documentation indicates multiple mandibular missing teeth (19, 20 21, 29, 
30 and 31) and poor bone support on many remaining teeth. A removable appliance with implants supporting 
and retaining the appliance would be medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of dental services have been met. Therefore, we decided that the Plan has to pre-
approve surgical placement of implant body: endosteal implant (D6010) and prefabricated abutment  includes 
modification and placement(D6056) Tooth #21, 23, 26.  
 
We also decided that the Plan does not have to pre-approve implant /abutment supported removable 
denture for edentulous arch - mandibular (D6111). 
 
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. 
 
This benefit includes only those items and services specifically listed in your Plan contract. Implant /abutment 
supported removable denture for edentulous arch - mandibular (D6111) is not covered under the Plans dental 
benefits. Therefore, we decided the Plan does not have to pre-approve an implant /abutment supported 
removable denture for edentulous arch - mandibular (D6111). 
 
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.