Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for a surgical extraction for tooth #28. We decided that the Plan does not 
have to pay for core buildup for teeth #27 and #30, pontics for teeth #28 and #29, and retainer crowns for teeth 
#27 and #30 .  
 
You asked the Plan to pay for a surgical extraction for tooth #28, core buildup for teeth #27 and #30, pontics 
for teeth #28 and #29, and retainer crowns for teeth #27 and #30 (D6750, D7210, D2950, D6240) provided on 
May 2, 2023. You say that the services should be covered as you disagree with the denial. The Plan says that 
the services denied correctly as they do not meet the clinical requirements to be approved. 
 
We decided that the Plan has to pay for a surgical extraction for tooth #28.  
 
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. 
 
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 pay for the item/service at issue. Our physician 
reviewer found a surgical extraction (D7210) of tooth #28 meets the criteria for coverage; it appears that the 
crown restoration is separated from the tooth which would require a surgical extraction. A fixed bridge 
replacing the missing teeth does not meet the criteria for coverage due to multiple missing posterior teeth. 
Record indicates tooth #30 is already gone.  
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for a surgical extraction for tooth #28.  
 
We also decided that the Plan does not have to pay for core buildup for teeth #27 and #30, pontics for 
teeth #28 and #29, and retainer crowns for teeth #27 and #30 . 
 
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. 
 
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 pay for the item/service at issue. Our physician 
reviewer found a surgical extraction (D7210) of tooth #28 meets the criteria for coverage; it appears that the 
crown restoration is separated from the tooth which would require a surgical extraction. A fixed bridge 
replacing the missing teeth does not meet the criteria for coverage due to multiple missing posterior teeth. 
Record indicates tooth #30 is already gone.  
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for core buildup for teeth #27 and #30, pontics for teeth #28 and #29, and retainer crowns 
for teeth #27 and #30. 
 
  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.