Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve interim crowns, teeth #7, 8, 9 (D2799 x3). We decided that the 
Plan does not have to pre-approve clinical crown lengthening, teeth #8 and 9 (D4249 x2).  
 
You asked the Plan to pre-approve interim crowns, teeth #7, 8, 9 (D2799 x3) and clinical crown lengthening, 
teeth #8 and 9 (D4249 x2). You say that the services are necessary. The Plan says that the services denied 
correctly as the enrollee does not meet the clinical requirements to be approved. 
 
We decided that the Plan has to pre-approve interim crowns, teeth #7, 8, 9 (D2799 x3).  
 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 dental services. Our reviewer says 
that D2799 is medically reasonable for teeth 7, 8 ,9, as these teeth will need to have the crowns removed to see 
if these teeth are restorable in particular teeth #7,8 as there is decay noted in the x-ray, and when decay is 
noted, one cannot determine the extent of the decay or the restorability of a tooth without removing the 
restoration. 
 
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 dental services have been met. Therefore, we decided that the Plan has to 
pre-approve interim crowns, teeth #7, 8, 9 (D2799 x3).  
 
We also decided that the Plan does not have to pre-approve clinical crown lengthening, teeth #8 and 9 
(D4249 x2). 
 
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 clinical crown lengthening, teeth #8 and 
9 (D4249 x2). Our reviewer says that the clinical documentation included was reviewed. Tooth number 7 has 
been root canal treated, has a large post, and decay underneath the crown. Teeth number 8 and 9 have existing 
crowns with open margins and see radiographic decay on tooth number 8. There is moderate to severe bone 
loss around teeth 8, 9. Tooth number appears to be possibly fractured and may be non-restorable. D4249 
Crown lengthening is not advised for these teeth due to the amount of bone loss around them. Crown 
lengthening is not medically reasonable or necessary. The final restorations can be placed without being too 
close to the bone. Based on the records reviewed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of clinical crown lengthening, teeth #8 and 9 (D4249 x2) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve clinical crown lengthening, teeth #8 and 9 
(D4249 x2). 
 
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.