Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the pontic (D6240) for tooth #13 and the retainer crown 
(D6750) for tooth #12. We decided that the Plan does not have to pre-approve the core buildup (D2950) for 
tooth #12 and #15, the pontic (D6240) for tooth #14, and the retainer crown (D6750) for tooth #15.  
 
You asked the Plan to pre-approve the core buildup (D2950) for tooth #12 and #15, pontics (D6240) for tooth 
#13 and #14, and retainer crowns (D6750) for tooth #12 and #15.. You say that you are appealing the denied 
dental services because you need your teeth to eat. The Plan says that the criteria for coverage for the pontics 
and retainer crowns was not met. Also, the denial of authorization for the core buildup is correct because they 
are not covered by the Plan. 
 
We decided that the Plan has to pre-approve the pontic (D6240) for tooth #13 and the retainer crown 
(D6750) for tooth #12.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not collect dental x-rays from their participating 
provider who ordered the requested dental services. Participating providers are considered agents of the Plan. 
Without this necessary documentation we are unable to make a determination as to whether the enrollee has 
met the criteria for coverage for the pontic (D6240) for tooth #13 and the retainer crown (D6750) for tooth #12. 
Therefore, we decided that the Plan has to pre-approve the pontic (D6240) for tooth #13 and the retainer crown 
(D6750) for tooth #12.  
 
We also decided that the Plan does not have to pre-approve the core buildup (D2950) for tooth #12 and 
#15, the pontic (D6240) for tooth #14, and the retainer crown (D6750) 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the pontic (D6240) for tooth #14 and the retainer crown (D6750) for tooth #15 was 
exhausted with the approval of the pontic (D6240) for tooth #13 and the retainer crown (D6750) for tooth #12. 
The core buildup is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not 
have to pre-approve the core buildup (D2950) for tooth #12 and #15, the pontic (D6240) for tooth #14, and the 
retainer crown (D6750) for tooth #15. 
  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.