Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the surgical extractions, erupted tooth represented by code 
D7210 for teeth #s 5, 12, 15, 20, 21 and 28-30. We also decided that the Plan does not have to pre-approve 
the surgical extractions, erupted tooth represented by code D7210 for teeth  #'s 2 and 6-13. 
 
You asked the Plan to pre-approve surgical extractions. You say that the medical records support the services 
requested. The Plan says that the decision to code a tooth as surgical was based on the clinical exam and the x-
ray. 
 
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 the dental 
services. when the services are medically necessary and reasonable. 
 
We decided that the Plan has to pre-approve the surgical extractions, erupted tooth represented by 
dental code D7210 for teeth #s 5, 12, 15, 20, 21 and 28-30.  
 
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 extractions tooth #'s. Our reviewer says 
that the coverage criteria has been met. Our physician review found that surgical extractions involve removal of 
bone and/or sectioning, and including elevation of mucoperiosteal flap. This is usually required if the coronal 
aspect of the tooth is badly broken down or missing and bone removal is required for access. A review of the 
documentation indicates that teeth #s 5, 12, 15, 20, 21 and 28-30 meet the criteria for surgical extractions. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extractions for tooth #'s 5, 12, 15, 20, 21 and 28-30 have been met. Therefore, 
we decided that the Plan has to pre-approve the surgical extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth code D7210 for teeth #s 5, 12, 15, 20, 21 and 28-30.  
 
We also decided that the Plan does not have to pre-approve the surgical extraction (D7210) of tooth #2 
and 6-13. 
 
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 extraction of tooth #2 and 6-13. Our 
physician reviewer found the documentation provided does not meet the criteria for the surgical extraction of 
tooth #2 and 6-13. These teeth appear to be amenable to elevation and/or forceps removal (D7140), which has 
already been approved on the initial authorization request.  
 
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 surgical extraction of tooth #2 and 6-13 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the surgical extraction (D7210) of tooth #2 and 6-13. 
 
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.