Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pre-approve surgical placement of implant body: endosteal implant teeth #'s 19, 29 and 
30 (D6010), and bone graft at time of implant placement teeth #'s 19 and 29 (D6104). You say that you have a 
broken tooth in your lower jaw and are missing a tooth that is unable to hold your current bridge. The Plan says 
there is no coverage for bone graft at time of implant placement. The Plan also says that that you do not have at 
least eight permanent back teeth that bite together that would be needed to approve the D6010 implant 
placement and may not provide the best tooth replacement option for your oral health. 
 
We decided that the Plan has to pre-approve one surgical placement of implant body: endosteal implant.  
 
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 one surgical placement of implant 
body: endosteal implant. Our reviewer says that this service is medically necessary. Our physician reviewer 
found the documentation indicates that teeth #'s 19, 29, and 30 are the only teeth needing replacement in the 
mandibular arch. Implants would be a method of replacing these teeth. However, due to the limits of the plan, 
one implant per year per tooth is allowed. The enrollee and provider must decide if a single implant replacing 
one tooth or a removable appliance replacing three teeth is the best interest of the patient. An implant would 
meet the criteria for coverage to the limit of the plan. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of one surgical placement of implant body: endosteal implant have been met. 
Therefore, we decided that the Plan has to pre-approve one surgical placement of implant body: endosteal 
implant.  
 
We also decided that the Plan does not have to pre-approve two surgical placements of implant body: 
endosteal implant, and bone grafts at time of implant placement. 
 
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, certain limitations apply. The record shows 
your benefit for the surgical placements of implant body: endosteal implant was exhausted on the appealed 
claim. Therefore, we decided that the Plan does not have to pre-approve two surgical placements of implant 
body: endosteal implant. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the bone grafts at time of implant 
placement are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the bone graft at time of implant placement teeth #'s 19 and 29. 
 
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.