Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain or ceramic retainer crown (D6740) for teeth 
17 and 20, localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular 
tissue per tooth, by report (D4381) for teeth 17 and 20, core buildup including any pins, when required (D2950) 
for teeth 17 and 20, and a porcelain or ceramic pontic (D6245) for teeth 18 and 19. 
 
You asked the Plan to pre-approve a porcelain or ceramic retainer crown (D6740) for teeth 17 and 20, localized 
delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue per tooth, by 
report (D4381) for teeth 17 and 20, core buildup including any pins, when required (D2950) for teeth 17 and 
20, and a porcelain or ceramic pontic (D6245) for teeth 18 and 19. You say that the claim was improperly 
denied. The Plan denied your request. The Plan says he Plan says that the criteria for the requested items 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. The Plan covers a porcelain or 
ceramic retainer crown (D6740) for teeth 17 and 20, localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue per tooth, by report (D4381) for teeth 17 and 20, core buildup 
including any pins, when required (D2950) for teeth 17 and 20, and a porcelain or ceramic pontic (D6245) for 
teeth 18 and 19 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 a porcelain or ceramic retainer crown 
(D6740) for teeth 17 and 20, localized delivery of antimicrobial agents via a controlled release vehicle into 
diseased crevicular tissue per tooth, by report (D4381) for teeth 17 and 20, core buildup including any pins, 
when required (D2950) for teeth 17 and 20, and a porcelain or ceramic pontic (D6245) for teeth 18 and 19. Our 
reviewer says that the enrollee does not meet the criteria for a porcelain or ceramic retainer crown (D6740) for 
teeth 17 and 20, localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue per tooth, by report (D4381) for teeth 17 and 20, core buildup including any pins, when 
required (D2950) for teeth 17 and 20, and a porcelain or ceramic pontic (D6245) for teeth 18 and 19. Our 
physician reviewer found there was no documentation indicating the need for the delivery of antimicrobial 
agents into diseased crevicular spaces of teeth numbers 17 and 20. Our physician reviewer also found that due 
to the multiple missing teeth bilaterally in the lower arch, other methods of replacement may be considered to 
be in the best interest of the enrollee. 
 
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 a porcelain or ceramic retainer crown (D6740) for teeth 17 and 20, localized 
delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue per tooth, by 
report (D4381) for teeth 17 and 20, core buildup including any pins, when required (D2950) for teeth 17 and 
20, and a porcelain or ceramic pontic (D6245) for teeth 18 and 19 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a porcelain or ceramic retainer crown (D6740) for teeth 17 and 20, 
localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue per 
tooth, by report (D4381) for teeth 17 and 20, core buildup including any pins, when required (D2950) for teeth 
17 and 20, and a porcelain or ceramic pontic (D6245) for teeth 18 and 19.