Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing-four or more teeth of the 
lower left quadrant (D4341) and periodontal scaling and root planing-one to three teeth of the upper left 
quadrant (D4342). We also decided that the Plan does not have to pre-approve periodontal scaling and root 
planing-four or more teeth of the lower right quadrant (D4341), periodontal scaling and root planing-one to 
three teeth of the upper right quadrant (D4342), and a complete upper denture (D5110).  
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items/services has 
already been exhausted. 
 
We decided that the Plan has to pre-approve periodontal scaling and root planing-four or more teeth of 
the lower left quadrant (D4341) and periodontal scaling and root planing-one to three teeth of the upper 
left quadrant (D4342). Specifically, the Plans contract states that periodontal scaling and root planing is 
covered once per quadrant every twenty four months. The Plan indicated that you have exhausted the allowable 
benefit for the indicated services requested in this case. However, the record does not show that periodontal 
scaling and root planing services were provided for the upper and lower left quadrants, or that the services were 
paid for by the Plan. The rules say that Medicare plans must make reasonable and diligent efforts to gather and 
forward information to the Independent Review Entity (IRE). The documentation provided does not 
demonstrate that you have exhausted the allowable benefit for the indicated services requested in this case. The 
Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the 
Plan has to pre-approve periodontal scaling and root planing-four or more teeth of the lower left quadrant 
(D4341) and periodontal scaling and root planing-one to three teeth of the upper left quadrant (D4342).     
 
We also decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or 
more teeth of the lower right quadrant (D4341), periodontal scaling and root planing-one to three teeth 
of the upper right quadrant (D4342), and a complete upper denture (D5110). Specifically, the Plans 
contract states the periodontal scaling and root planing is covered once per quadrant every twenty four months. 
You previously received these indicated services on July 11, 2022, less than twenty four months prior, which 
were paid for by the Plan. Therefore, you have exhausted the allowable benefit for these services. Additionally, 
the Plans contract states that complete or partial dentures are covered once every 60 months per arch. You 
previously received an upper partial denture on September 28, 2022, less than 60 months prior, which was paid 
for by the Plan. Therefore, you have exhausted the allowable benefit for the requested dental item at this time. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or 
more teeth of the lower right quadrant (D4341), periodontal scaling and root planing-one to three teeth of the 
upper right quadrant (D4342), and a complete upper denture (D5110).  
 
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.