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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit.  
 
The Manual states that coverage criteria for crowns is as follows:  
 
I. Pre-Authorization Documentation 
 A. Documentation may be needed for pre-authorization of procedure: 
  1. Panorex or, at minimum, 4 bitewing radiographs showing clearly the adjacent and opposing 
  teeth 
  2. Treatment rendered without necessary pre-authorization is subject to retrospective review. 
II. Codes 
 A. Plan adheres to the code definitions as described in the American Dental Association Current 
 Dental Terminology Users Manual. 
 B. In general, crowns are allowed only for teeth needing multi-surface restorations where amalgams and 
 other materials have a poor prognosis. 
 C. Molars must have pathologic destruction to the tooth by caries or trauma, and must involve four or 
 more surfaces and two or more cusps. 
 D. Bicuspids must have pathologic destruction to the tooth by caries or trauma, and must involve three 
 or more surfaces and at least one cusp. 
 E. Anterior teeth must have pathologic destruction to the tooth by caries or trauma, and must involve 
 four or more surfaces and at least 50% of the incisal edge. 
 F. Crown build-up procedures are allowed on teeth that meet crown criteria, where clinical crown 
 breakdown is at a level where the build-up material is necessary for crown retention. 
 G. A request for a crown following root canal therapy must meet the following criteria: 
  1. One month must have passed since the root canal therapy was completed. 
  2. Request must include a dated post-endodontic radiograph. 
  3. Tooth must be filled within two millimeters of the radiological apex, unless there is a  
  curvature or calcification of the canal that limits the ability to fill the canal to the apex. 
  4. The filling must be properly condensed/obdurated. 
  5. To be covered, a tooth must oppose a crown or denture in the opposite arch or be an abutment 
  for a partial denture. 
  6. The patient must be free from active and advanced periodontal disease. 
  7. The fee for crowns includes the temporary crown that is placed on the prepared tooth and 
  worn while the permanent crown is being fabricated. 
  8. Pre-fabricated or cast post and core procedures are allowed on endodontically treated teeth 
  where clinical crown breakdown is at a level where the post and core is necessary for crown 
  retention.