Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crown - porcelain/ceramic and core buildup for tooth #15. 
We also decided that the Plan does not have to pre-approve the crown - porcelain/ceramic and core buildup for 
tooth #19.  
 
You asked the Plan to pre-approve crowns - porcelain/ceramic (D2740), core buildup, including any pins when 
required (D2950) for teeth #'s 15 and 19. You say that you are in severe pain in these teeth, and sensitive to hot 
& cold which gives you headaches. You also say that the fractures in these teeth, which at any time can break 
and create emergency dental care. The Plan says that there is no evidence that the affected teeth meet the 
required criteria for approval (more than half of the tooth must be damaged due to decay or injury). 
 
We decided that the Plan has to pre-approve the crown - porcelain/ceramic and core buildup for tooth 
#15.  
 
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 crowns and core buildup. Our reviewer 
says that tooth 15 has an existing large filling and decay/fracture that is seen on the cheek side of the tooth. There is 
minimal tooth structure around the filling, and the tooth needs a full coverage crown to decrease the risk of the tooth 
fracturing. After the decay, existing filling, and fracture is removed more than 50% of your natural tooth structure 
will be missing. D2950 and D2740 for tooth #15 is 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 the crowns and core buildup have been met. Therefore, we decided that the Plan 
has to pre-approve the crown - porcelain/ceramic and core buildup for tooth #15.  
 
We also decided that the Plan does not have to pre-approve the crown - porcelain/ceramic and core 
buildup for tooth #19. 
 
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 pre-approve the crown - porcelain/ceramic and core 
buildup for tooth #19. Our reviewer says that the photos that showed tooth 19 were blurry and am unable to see any 
fractures or decay in the photo. The x-ray also does not show decay. Tooth 19 has recession of gums that is severe 
possible ~5-6mm. The severe recession has exposed the root of your teeth which are sensitive areas when exposed 
to hot or cold temperatures. This exposure of the root of your tooth or untreated periodontal disease may be the 
cause of your hot and cold sensitivity you feel that would need to be treated with other options other than a buildup 
and crown. D2950 and D2740 for tooth 19 is not medically reasonable or necessary based on the information 
reviewed. 
 
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 crown - porcelain/ceramic and core buildup for tooth #19 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the crown - porcelain/ceramic and core 
buildup for tooth #19. 
 
 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.