Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the surgical placement of implant body (D6010) for tooth #4 
and #30, a custom abutment (D6057) for tooth #4 and #30, and an abutment supported to a crown 
(D6058) for tooth #4 and #30. We decided that the Plan does not have to pre-approve the bone graft (D6104) 
for tooth #4.  
 
You asked the Plan to pre-approve the surgical placement of implant body (D6010) for tooth #4 and #30, a 
custom abutment (D6057) for tooth #4 and #30, an abutment supported to a crown (D6058) for tooth #4 and 
#30, and a bone graft (D6104) for tooth #4.. You say that the requested dental services are medically necessary. 
The Plan says that the denial of authorization for the implant services is correct because implants are covered to 
replace 1 tooth in the same arch and can only be missing 1 tooth in an arch where the implant is requested. 
Also, the bone graft is not covered by the Plan. 
 
We decided that the Plan has to pre-approve the surgical placement of implant body (D6010) for tooth 
#4 and #30, a custom abutment (D6057) for tooth #4 and #30, and an abutment supported to a crown 
(D6058) for tooth #4 and #30.  
 
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 surgical 
placement of implant body, a custom abutment, and an abutment supported to a crown 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 surgical placement of implant body 
(D6010) for tooth #4 and #30, a custom abutment (D6057) for tooth #4 and #30, and an abutment supported to 
a crown (D6058) for tooth #4 and #30. Our reviewer says that the surgical placement of implant body, a custom 
abutment, and an abutment supported to a crown is medically necessary. Our physician reviewer found that the 
services requested to replace teeth #4 and #30 are medically reasonable and necessary. No other teeth need 
replacement in either arch and replacing teeth #4 and #30 would give the enrollee adequate masticatory 
function.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical placement of implant body (D6010) for tooth #4 and #30, a custom 
abutment (D6057) for tooth #4 and #30, and an abutment supported to a crown (D6058) for tooth #4 and #30 
have been met. Therefore, we decided that the Plan has to pre-approve the surgical placement of implant body 
(D6010) for tooth #4 and #30, a custom abutment (D6057) for tooth #4 and #30, and an abutment supported to 
a crown (D6058) for tooth #4 and #30.  
 
We also decided that the Plan does not have to pre-approve the bone graft (D6104) for tooth #4. 
 
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 bone graft is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the bone graft 
(D6104) for tooth #4. 
 
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.