Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crown (D2740) for tooth #8 and #9. We decided that the Plan 
does not have to pre-approve the intraoral radiographic images (D0230).  
 
You asked the Plan to pre-approve the intraoral radiographic images (D0230) and a crown (D2740) for tooth #8 
and #9.. You say that you are appealing the denied dental services. The Plan says that the denial for the dental 
services is correct, because the crowns are to restore damage due to attrition, abrasion, erosion or abfraction. 
 
We decided that the Plan has to pre-approve the crown (D2740) for tooth #8 and #9.  
 
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 crowns 
(D2740) 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 crown (D2740) for tooth #8 and #9. 
Our reviewer says that the crowns (D2740) for teeth #8 and #9 are medically necessary. Our physician 
reviewer found that the x-rays were reviewed and noted some radiolucent areas on the front teeth in the upper 
jaw. Clinical notes from the provider June 23, 2023, stated that there was decay, and fillings were placed in 
teeth #8, #9, and #10. From the x-rays, teeth #8 and #9 are missing more than 50% of their tooth structure, and 
crowns are recommended, and meet the criteria for crowns.  
 
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 crown (D2740) for tooth #8 and #9 have been met. Therefore, we decided 
that the Plan has to pre-approve the crown (D2740) for tooth #8 and #9.  
 
We also decided that the Plan does not have to pre-approve the intraoral radiographic images (D0230). 
 
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 intraoral 
radiographic images (D0230) 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 intraoral radiographic images 
(D0230). Our reviewer says that the requested periapical x-rays (D0230) are not medically necessary. Our 
physician reviewer found that the periapical x-rays that provider is requesting is for tooth #7, #10, #22, #27, 
and #31. There is no clinical documentation as to why the provider is requesting additional x-rays. Normally, 
within the standards of dentistry, x-rays are taken when the crowns are cemented, but the x-rays are a part of 
the crown procedure. The x-rays requested do not list tooth #8 and #9.  
 
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 intraoral radiographic images (D0230) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the intraoral radiographic images (D0230). 
  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.