Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an extraction of an erupted tooth (D7210) for teeth numbers 
28 and 23. We decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with 
extractions (D7311) of the lower left quadrant, alveoloplasty in conjunction with extractions (D7310) of the 
lower right quadrant, and inhalation of nitrous oxide (D9230).  
 
You asked the Plan to pre-approve an extraction of an erupted tooth (D7210) for teeth numbers 28 and 23, an 
alveoloplasty in conjunction with extractions (D7311) of the lower left quadrant, alveoloplasty in conjunction 
with extractions (D7310) of the lower right quadrant, and inhalation of nitrous oxide (D9230). You say that 
appealing with supporting records. The Plan says that an alveoloplasty in conjunction with extractions (D7311) 
of the lower left quadrant, alveoloplasty in conjunction with extractions (D7310) of the lower right quadrant, 
and inhalation of nitrous oxide (D9230) are not covered by the Plan. The Plan also says that to be able to 
authorize an extraction of an erupted tooth (D7210) for teeth numbers 28 and 23, the x-rays of your teeth need 
to show that your dentist would need to cut the gum near the tooth, cut the tooth into pieces, or need to also 
remove some bone to be able to remove the tooth. The x-rays your dentist sent us do not show this. 
 
We decided that the Plan has to pre-approve an extraction of an erupted tooth (D7210) for teeth 
numbers 28 and 23.  
 
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 an extraction of an erupted tooth 
(D7210) for teeth numbers 28 and 23. Our reviewer says that this service is medically reasonable and 
necessary. Our physician reviewer found for tooth number 28, this tooth would require a surgical extraction in 
order to be removed, because this tooth will fracture, the curved part of the root would remain in the jawbone, 
and would require removal of bone around the tooth to remove it. The physician reviewer also found that for 
tooth number 23, a cut in the gums is required in order to remove this tooth. The physician reviewer also found 
that there is severe bone loss around the tooth, which may need to be surgically extracted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an extraction of an erupted tooth (D7210) for teeth numbers 28 and 23 have 
been met. Therefore, we decided that the Plan has to pre-approve an extraction of an erupted tooth (D7210) for 
teeth numbers 28 and 23.  
 
We also decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with 
extractions (D7311) of the lower left quadrant, alveoloplasty in conjunction with extractions (D7310) of 
the lower right quadrant, and inhalation of nitrous oxide (D9230). 
 
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, an alveoloplasty in conjunction with 
extractions (D7311) of the lower left quadrant, alveoloplasty in conjunction with extractions (D7310) of the 
lower right quadrant, and inhalation of nitrous oxide (D9230) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with 
extractions (D7311) of the lower left quadrant, alveoloplasty in conjunction with extractions (D7310) of the 
lower right quadrant, and inhalation of nitrous oxide (D9230). 
 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.