Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve pontics (D6245) for tooth #7 and #13, and retainer crowns 
(D6750) for tooth #6, #8, and #9. We decided that the Plan does not have to pre-approve the implant 
placement (D6010), the custom abutments (D6057), and the implant supported to crown (D6066) for tooth #2, 
#3, #12, #14.  
 
You asked the Plan to pre-approve the implant placement (D6010), the custom abutments (D6057), and the 
implant supported to crown (D6066) for tooth #2, #3, #12, #14, pontics (D6245) for tooth #7 and #13, and 
retainer crowns (D6750) for tooth #6, #8, and #9.. You say that you cannot wear dentures. The Plan says that 
the enrollee is missing more than 1 upper front tooth or only 2 lower front teeth; therefore, the criteria for a 
bridge was not met.  Dental implants and all associated services are not covered by the Plan. 
 
We decided that the Plan has to pre-approve pontics (D6245) for tooth #7 and #13, and retainer crowns 
(D6750) for tooth #6, #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 pontics and 
retainer crowns 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 pontics (D6245) for tooth #7 and #13, 
and retainer crowns (D6750) for tooth #6, #8, and #9. Our reviewer says that the criteria for coverage as 
medically necessary for a fixed bridge replacing tooth #7 with a pontic (D6245) using teeth #6, #8 and #9 as 
abutment retainers (D6750). Our physician reviewer found that the documentation indicates that the enrollee 
had a stroke and is unable to manipulate a removable partial denture. A fixed bridge replacing tooth #7 is 
medically reasonable and necessary. Due to the circumstances of the enrollee's disability and inability to wear a 
removable partial denture the implant procedures are medically necessary and may be covered to the limit of 
the insurance coverage.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pontics (D6245) for tooth #7 and #13, and retainer crowns (D6750) for tooth 
#6, #8, and #9 have been met. Therefore, we decided that the Plan has to pre-approve pontics (D6245) for tooth 
#7 and #13, and retainer crowns (D6750) for tooth #6, #8, and #9.  
 
We also decided that the Plan does not have to pre-approve the implant placement (D6010), the custom 
abutments (D6057), and the implant supported to crown (D6066) for tooth #2, #3, #12, #14. 
 
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 requested the implant placement, 
the custom abutments, and the implant supported to crown are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve the implant placement (D6010), the custom 
abutments (D6057), and the implant supported to crown (D6066) for tooth #2, #3, #12, #14. 
 
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.