Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the follow-up visits. We decided that the Plan does not have to 
pre-approve a panoramic x-ray and an unlisted maxillofacial procedure.  
 
You asked the Plan to pre-approve follow up visits, a panoramic x-ray (70355), and unlisted maxillofacial 
prosthetic procedure (21089). You say that this is medically necessary. The Plan says that treatment related to 
temporomandibular joint dysfunction is not covered by Medicare or the Plan.  
We decided that the Plan has to pre-approve the follow-up visits.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 for follow-up visits. Our reviewer says that the enrollee 
needs to have subsequent visits to evaluate their symptoms. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve the follow-up visits.  
 
We also decided that the Plan does not have to pre-approve a panoramic x-ray and an unlisted 
maxillofacial procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 for the dental procedures. Our reviewer says that the 
working diagnoses made by the provider for the enrollee are, obstructive sleep apnea, sleep related bruxism, 
deviation in the opening and closing of the mandible, and articular disc disorder of left temporomandibular 
joint. These diagnoses were made solely from a clinical examination by the provider. In order to diagnose 
articular disc disorder, magnetic resonance imaging (MRI) must be taken. Once a definitive diagnosis has been 
made, treatment options can be recommended to the enrollee. It would be in the best interest of the enrollee to 
start with the most conservative form of treatment. With the current clinical documentation, a centric relation 
appliance is not medically reasonable or necessary. A definitive diagnosis needs to be made, prior to an 
appliance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a panoramic x-ray and an unlisted maxillofacial procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a panoramic x-ray and an unlisted 
maxillofacial procedure. 
 
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.