Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6242) for tooth #13 and a retainer crown 
(D6750 and D6752) for tooth #12 and #14. 
 
You asked the Plan to pre-approve the dental services. You say that the bridge is important to help the enrollee 
chew and the removable prothesis is not ideal. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because there was no information stating why a denture cannot be 
used to replace the missing teeth. 
 
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 the dental 
services 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 the dental services. Our reviewer says 
that the bridge is not medically necessary. Our physician reviewer found from the x-rays, tooth #13 is the only 
tooth that can be determined as not present in the mouth. There is evidence of the tooth being extracted, as 
there is an outline of the tooth root noted on the x-rays. Tooth #1, #16, #17, and #32 is not captured in these x-
rays, and they may be in the oral cavity. These are teeth that do not impact oral function when they are 
removed.  
 
The periodontal charting record show that that gum and bone structures around teeth #12 and #14 area stable. 
There is moderate bone loss around tooth #14, and moderate bone loss on one side of tooth #12 and severe 
bone loss on the other side of tooth #12. Based on the information provided, a dental bridge is not medically 
reasonable and necessary for the enrollee due to the extent of bone loss around tooth #12.  
 
Dental bridges require teeth with a strong foundation (enough bone and gum around the teeth) in order to hold 
a bridge. When there is significant bone loss around one of the anchors of a bridge, the bridge can fail, 
therefore a retainer crown (D6750) for tooth #12, a retainer crown (D6752) for tooth #14, and a pontic (D6242) 
for tooth #13 are not medically reasonable or necessary. The sinus area is close to the root of tooth #12 and 
where tooth #13 once was. The options for replacement of tooth #13 are, a dental bridge, an implant, or a 
partial denture. Placing an implant would require more extensive treatment as sinus lift would need to be done 
in order to accommodate an implant. A partial denture would not be reasonable as there is only tooth #13 
missing. Food can commonly get lodged underneath the denture and the teeth that hold the denture in may 
develop caries. Also of note is possible drifting of teeth #12 and #14 into the area where tooth #13 once was. 
There may not be enough room to place a single denture tooth. Other treatment options may be more ideal for 
the enrollee to restore their function. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic (D6242) for tooth #13 and a retainer crown (D6750 and D6752) for tooth #12 
and #14.