Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve removal of foreign body (10120), excision of bone (eg, for 
osteomyelitis or bone abscess); mandible (21025), excision of bone (eg, for osteomyelitis or bone abscess); 
facial bone(s) (21026), augmentation, mandibular body or angle (21127), osteotomy, mandible, segmental 
(21198), osteoplasty, facial bones; reduction (21209), graft, bone; nasal, maxillary or malar areas (21210), 
graft, bone; mandible (21215), sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of 
antrochoanal polyps (31030), and biopsy, vestibule of mouth (40808). 
 
You asked the Plan to pre-approve removal of foreign body, excision of bone (eg, for osteomyelitis or bone 
abscess); mandible, excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s), excision of bone 
(eg, for osteomyelitis or bone abscess); facial bone(s), osteotomy, mandible, segmental, osteoplasty, facial 
bones; reduction, graft, bone; nasal, maxillary or malar areas, graft, bone; mandible, sinusotomy, maxillary 
(antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps, and biopsy, vestibule of mouth. 
You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has 
not been established. Therefore, coverage criteria have not been met. 
 
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 the services 
are medically necessary. 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 removal of foreign body, excision of 
bone (eg, for osteomyelitis or bone abscess); mandible, excision of bone (eg, for osteomyelitis or bone 
abscess); facial bone(s), excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s), osteotomy, 
mandible, segmental, osteoplasty, facial bones; reduction, graft, bone; nasal, maxillary or malar areas, graft, 
bone; mandible, sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps, and biopsy, vestibule of mouth. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found based on the medical and dental records provided and the details of the supplemental 
dental benefits in the Evidence of Coverage for the Plan, the requested dental services are eligible for coverage under the dental benefit plan (but not under 
original Medicare).  
 
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 removal of foreign body, excision of bone (eg, for osteomyelitis or bone 
abscess); mandible, excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s), excision of bone 
(eg, for osteomyelitis or bone abscess); facial bone(s), osteotomy, mandible, segmental, osteoplasty, facial 
bones; reduction, graft, bone; nasal, maxillary or malar areas, graft, bone; mandible, sinusotomy, maxillary 
(antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps, and biopsy, vestibule of mouth 
have been met. Therefore, we decided that the Plan has to pre-approve removal of foreign body (10120), 
excision of bone (eg, for osteomyelitis or bone abscess); mandible (21025), excision of bone (eg, for 
osteomyelitis or bone abscess); facial bone(s) (21026), augmentation, mandibular body or angle (21127), 
osteotomy, mandible, segmental (21198), osteoplasty, facial bones; reduction (21209), graft, bone; nasal, 
maxillary or malar areas (21210), graft, bone; mandible (21215), sinusotomy, maxillary (antrotomy); radical 
(Caldwell-Luc) without removal of antrochoanal polyps (31030), and biopsy, vestibule of mouth (40808).  
 
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.