Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health plan contract says Additional InformationA. Crowns are limited to one per tooth per five years, four per calendar year, with no more than two crowns per arch. Crowns are not a covered benefit if:1. A lesser means of restoration is possible. 2. Tooth has subosseous and/or furcation carie3. Tooth has advanced periodontal disease4. Tooth is a third molar, unless it is an abutment for a partial denture5. Tooth is a primary tooth with exfoliation imminent6. Tooth has crown less than five years old, which is dislodged, broken or lost7. Crowns are being planned to alter vertical dimension. If performed, these must be done with agreement ofthe patient to assume all costs. Such procedures includebut are not limited to restorations, procedures or applications done primarilyto treat attrition,realign the dentition, splinting, full-mouth rehabilitation or equilibration, and the treatment of TMD Syndrome. CodesA. The dental plan adheres to the code definitions as described in the American Dental Association CurrentDental Terminology User's Manual.B.In general, crownsare allowed only for teeth needing multi-surface restorations where amalgams and other materials have a poor prognosis.C.  Molars must have pathologic destruction to the toothby cariesor trauma, and must involve four or more surfacesand two or more cusps.D. Bicuspids must have pathologic destructionto the tooth by caries or trauma, and must involvethree or more surfaces and at least one cusp.E.  Anterior teeth musthave pathologic destructiontothetooth bycariesor trauma, and must involve four or more surfaces and at least 50% of the incisal edge.F. Crown build-up procedures are allowed on teeth that meet crown criteria, where clinical crown breakdown is at a level where the build-up material is necessary for crown retention.G. Replacement crowns are allowed only on teeth with recurrent decayor missing crowns. Openmargins, in the absence of decay, are considered cleansable and do not require replacement. H. A request for a crown following root canal therapy must meet the following criteria:1. One month must have passed since the root canal therapy was completed.2. Request must include a dated post-endodontic radiograph.3. Tooth must be filled within two millimeters of the radiological apex, unless there is a curvature or 
calcification of the canal that limits the ability to fill the canal to the apex.4. The filling must be properly condensed/obturated.5. To be covered, a tooth must oppose a crown or denture in the opposite arch or be an abutment for a partial denture.6. The patient must be free from active and advanced periodontal disease.7. The fee for crowns includes the temporary crown that is placed on the prepared tooth and worn while the permanent crown is beingfabricated.8.  Prefabricated or castpost and core procedures are allowed on endodontically treated teeth whereclinical crown breakdown is at a level where the postand core is necessaryfor crown retention. You can find this information in on page 30 of the plan's 2021 Dental Office Reference Handbook.