Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
tooth #12, a prefabricated abutment (D6056) for tooth #10 and #12, and the abutment supported to crown 
(D6058) for tooth #10 and #12. 
 
You asked the Plan to pre-approve the dental services. You say that you need the 2 implants approved. The 
Plan denied your request. The Plan says the denial of the surgical placement of implant body is correct because 
you do not have at least 8 permanent back teeth. Also, your benefit for the prefabricated abutment and the 
abutment supported to crown has already been exhausted. 
  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. The Plan covers the dental 
services 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 the dental services. Our reviewer says 
that the surgical placement of implant body (D6010) for tooth #12 is not medically necessary. Our physician 
reviewer found that there was a letter from the enrollees dental provider. There was also a panoramic x-ray 
dated May 5, 2023, included. The enrollee is missing many teeth in the upper jaw. There are two implants 
present in teeth #7 and #10 area. There are only 3 natural teeth present. The enrollees dentist is requesting 
prefabricated abutments and crowns on teeth #7 and #10, and implants, prefabricated abutments, and crowns 
for teeth #8 and #12. Regarding the prefabricated abutment and the abutment supported to crown for teeth #7 
and #10, these 2 procedures would restore the implants that have already been placed. There is still the issue 
that the enrollee is missing many teeth, and implants and restorations for teeth #8 and #12 alone would not 
restore the enrollees ability to eat, and they would only be providing 2 more teeth for the enrollee. The 
enrollee is missing teeth on the right and left side of his upper jaw. There may be better alternative treatment 
options that can help the enrollee to eat, such as a partial denture, or potentially other denture options. The front 
teeth allow a person to cut up their food, and the back teeth allows a person to grind up their food. I agree with 
the plans statement that more information is needed regarding the plans for restoring the enrollees oral 
condition. 
 
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 the surgical placement of implant body have not been met. The record shows 
the Plan pre-approved a prefabricated abutment (D6056) for tooth #7 and #8, and the abutment supported to 
crown (D6058) for tooth #7 and #8; therefore, your benefit for the requested items or services was exhausted 
on the date of approval of May 31, 2023. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (D6010) for tooth #12, a prefabricated abutment (D6056) for tooth #10 and 
#12, and the abutment supported to crown (D6058) for tooth #10 and #12.