Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve surgical placement of implant body: endosteal implant 
(D6010) and custom-fabricated abutment-includes placement (D6057) Tooth #22 and 27. We decided that 
the Plan does not have to pre-approve LW-overdenture-complete mandibular (D5865), surgical access to an 
implant body (second stage implant surgery) (D6011) Tooth # 22 and 27 and alveoloplasty in conjunction with 
extractions - four or more teeth or tooth spaces, per quadrant (D7310) x2.  
 
You asked the Plan to pre-approve D6010 Tooth # 22 and 27 and D6057 Tooth # 22 and 27, D5865, D6011 
Tooth # 22 and 27 and D7310 x2. You say that you do not have enough bone to keep dentures in place. The 
Plan denied your request. The Plan says that the requested services do not meet criteria for dental implants. 
 
We decided that the Plan has to pre-approve surgical placement of implant body: endosteal implant 
(D6010) and custom-fabricated abutment-includes placement (D6057) Tooth #22 and 27. 
 
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 has to pre-approve 
D6010 and D6057 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 dental services. Our physician 
reviewer found the documentation provided meets the criteria for coverage for implant body (D6010) and 
custom-fabricated abutment-includes placement (D6057) Tooth #22 and 27. A review of the documentation 
indicates that due to the atrophy of the mandibular ridge, dental implants would increase the stability and 
retention or a complete mandibular denture and provide the patient with adequate masticatory function. Implant 
bodies D6010 and custom fabricated abutments D6057 in areas #22 and 27 meet the criteria of medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of dental services have been met. Therefore, we decided that the Plan has to pre-
approve surgical placement of implant body: endosteal implant (D6010) and custom-fabricated abutment-
includes placement (D6057) Tooth #22 and 27. 
  We also decided that the Plan does not have to pre-approve LW-overdenture-complete mandibular 
(D5865), surgical access to an implant body (second stage implant surgery) (D6011) Tooth # 22 and 27 
and alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant 
(D7310) x2. 
 
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. LW-overdenture-complete 
mandibular (D5865) and surgical access to an implant body (second stage implant surgery) (D6011) are not 
covered under the Plans dental benefits.  
 
This benefit includes only those items and services specifically listed in your Plan contract. LW-overdenture-
complete mandibular (D5865), surgical access to an implant body (second stage implant surgery) (D6011) are 
not covered under the Plans dental benefits. Therefore, we decided the Plan does not have to pre-approve LW-
overdenture-complete mandibular (D5865), surgical access to an implant body (second stage implant surgery) 
(D6011). 
 
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. Alveoloplasty in conjunction 
with extractions - four or more teeth or tooth spaces, per quadrant (D7310) is covered but prior authorization is 
required for procedures performed by a specialist. Medical necessity must be demonstrated for procedures 
D7340  D7997. 
 
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 dental services. Our physician 
reviewer found the documentation provided does not meet the criteria for coverage for alveoloplasty in 
conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310). A review of the 
documentation indicates this does not meet the criteria of four or more teeth. Therefore, we decided the Plan 
does not have to pre-approve alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, 
per quadrant (D7310). 
 
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.