Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction of roots with bone (D7250) on teeth #11, 
#5, and #6, the surgical extraction (D7210) on teeth #28, and #4, the dental surgery that shapes the bone that 
supports the teeth upper left, quadrant (D7321), the dental surgery that shapes the bone that supports the teeth, 
upper right quadrant (D7311), and the removal of extra bone in the lower jaw, lower right quadrant (D7473). 
 
You asked the Plan to pre-approve the extraction of roots with bone (D7250) on teeth #11, #5, and #6, the 
surgical extraction (D7210) on teeth #28, and #4, the dental surgery that shapes the bone that supports the teeth 
upper left, quadrant (D7321), the dental surgery that shapes the bone that supports the teeth, upper right 
quadrant (D7311), and the removal of extra bone in the lower jaw, lower right quadrant (D7473). You say that 
teeth #5, #6, and #11 are broken off at the gum line and will require a flap to be made in the gum to remove the 
root tips/teeth #4 and #28 are decayed and will require surgical removal because of the level of decay. The Plan 
denied your request. The Plan says the services are not medically necessary. The Plan says the record does not 
support the specific type of extractions requested by the enrollee's dentist. Codes D7321, D7311, DD7473 are 
not covered services. 
 
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 extraction 
of roots with bone (D7250) on teeth #11, #5, and #6 and the surgical extraction (D7210) on teeth #s 28, and #4, 
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 extraction of roots with bone 
(D7250) on teeth #11, #5, and #6 and the surgical extraction (D7210) on teeth #28, and #4. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the panoramic x-ray shows all the 
teeth in question intact with coronal structure present, though it appears restorations are present in the cervical 
areas which could complicate the extractions above what would be expected for simple extractions. The code 
D7250 is reserved for situations where there is a residual root that in need of removal requiring the cutting of 
bone. Currently, teeth #5, #6 and #11 do not present as residual roots, and the code provided is inappropriate. 
Teeth #4 and #28 have most of the coronal structure still present, and it would not be appropriate to request a 
code for extraction with removal of bone (D7210) as it cannot be predicted that cutting of bone would be 
necessary for either of these teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the extraction of roots with bone (D7250) on teeth #11, #5, and #6 and the 
surgical extraction (D7210) on teeth #28, and #4 have not been met.  
 
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, the dental surgery that shapes the bone 
that supports the teeth upper left, quadrant (D7321), the dental surgery that shapes the bone that supports the 
teeth, upper right quadrant (D7311), and the removal of extra bone in the lower jaw, lower right quadrant 
(D7473) are not among those covered under this benefit. 
 
Therefore, we decided that the Plan does not have to pre-approve the extraction of roots with bone (D7250) on 
teeth #11, #5, and #6, the surgical extraction (D7210) on teeth #28, and #4, the dental surgery that shapes the 
bone that supports the teeth upper left, quadrant (D7321), the dental surgery that shapes the bone that supports 
the teeth, upper right quadrant (D7311), and the removal of extra bone in the lower jaw, lower right quadrant 
(D7473).