Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #9 and core buildup (D2950) for 
tooth #9, #11, and #14. We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #26 
and #27 and core buildup (D2950) for tooth #10, #22, #23, #24, #24, #25, #26, and #27.  
 
You asked the Plan to pre-approve a crown (D2740) for tooth #9, #26, and #27 and the core buildup (D2950) 
for tooth #9, #10, #11, #14, #22, #23, #24, #24, #25, #26, and #27.. You say that you need the services done 
before your teeth become more severe. The Plan says that the denial of authorization for these services is 
correct, because they did not meet the criteria for coverage. 
 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #9 and core buildup (D2950) for 
tooth #9, #11, and #14.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers crowns and 
core buildup when the services are medically necessary and reasonable. 
 
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 a crown (D2740) for tooth #9 and core 
buildup (D2950) for tooth #9, #11, and #14. Our reviewer says that the crown for tooth #9 and core buildup for 
tooth #9, #11, and #14 is medically necessary. Our physician reviewer found that the enrollee acknowledged 
that their teeth have attrition and wants crowns on them so they don't get more severe, and that it can prevent 
unnecessary loss of further tooth structure. A full mouth series of x-rays were also included. There is a bridge 
from teeth #11 to #14. The periapical x-rays of these teeth show that there are gaps in between the margin of 
the bridge and the tooth structure, and these areas can trap debris leading to decay in these areas. It is also of 
note that the existing bridge is a 3-unit bridge, 2 retainer crowns on tooth #11 and #14, and a pontic for tooth 
#13. The space is limited between tooth #11 and #14, and can only accommodate 1 pontic, and can be 
considered a pontic for tooth #12 or tooth #13.  
 
A replacement bridge is medically necessary. Core buildup (D2950) for teeth #11 and #14 may be medically 
reasonable and necessary, if after removal of the bridge, there is decay underneath. The plan has since approved 
bridge for teeth #11 to #14. 
 
Core buildup (D2950) and a crown (D2740) for tooth #9 is medically necessary, the tooth is missing more than 
50% of its natural tooth structure and needs to be built up with a filling to retain the crown. When this much 
tooth structure is missing, a full coverage crown is required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown (D2740) for tooth #9 and core buildup (D2950) for tooth #9, #11, and 
#14 have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for tooth #9 and 
core buildup (D2950) for tooth #9, #11, and #14.  
  
We also decided that the Plan does not have to pre-approve a crown (D2740) for tooth #26 and #27 and 
core buildup (D2950) for tooth #10, #22, #23, #24, #24, #25, #26, and #27. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers crowns and 
core buildup when the services are medically necessary and reasonable. 
 
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 a crown (D2740) for tooth #26 and #27 
and core buildup (D2950) for tooth  #10, #22, #23, #24, #24, #25, #26, and #27. Our reviewer says that the 
crown for tooth #26 and #27 and core buildup for tooth #10, #22, #23, #24, #24, #25, #26, and #27 is not 
medically necessary. Our physician reviewer found that the enrollee acknowledged that their teeth have 
attrition and wants crowns on them so they don't get more severe, and that it can prevent unnecessary loss of 
further tooth structure. A full mouth series of x-rays were also included. There is a bridge from teeth #11 to 
#14. The periapical x-rays of these teeth show that there are gaps in between the margin of the bridge and the 
tooth structure, and these areas can trap debris leading to decay in these areas. It is also of note that the existing 
bridge is a 3-unit bridge, 2 retainer crowns on tooth #11 and #14, and a pontic for tooth #13. The space is 
limited between tooth #11 and #14, and can only accommodate 1 pontic, and can be considered pontic for tooth 
#12 or tooth #13.  
 
There was no clinical documentation in regards for the plan of teeth #10, #23, #24, #25, #26, and #27, except 
for the pre-authorization for core buildups. Core buildups are placed when tooth structure needs repaired so that 
it can retain a crown. Core buildup (D2950) is associated with a crown code. Crowns for teeth #23, #24, #25, 
and #26 were not requested in the pre-authorization, and there was no documentation that these teeth will need 
a crown in the future. There was no decay noted on the x-rays of these teeth. Based on this information, core 
buildup (D2950) for teeth #10, #23, #24, #25, and #26, are not medically reasonable or necessary. 
 
Teeth #22 and #27 show wear on the edge of these teeth. Attrition alone is not a reason to have a crown placed. 
Additional documentation is needed to support the need for crowns. There may be other more conservative 
treatment that can address the enrollee's concern. Because the crowns are deemed not medically necessary, the 
core buildup for teeth #22 and #27 are also not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Plan's rules for coverage of a crown (D2740) for tooth #26 and #27 and core buildup (D2950) for teeth #10, 
#22, #23, #24, #24, #25, #26, and #27 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a crown (D2740) for tooth #26 and #27 and core buildup (D2950) for tooth #10, #22, #23, #24, 
#24, #25, #26, and #27. 
 
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.