Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve crowns (D2740) for teeth #'s 27 and 28. We decided that the Plan does not have to pre-approve crowns for teeth #'s 22, 23, 24, 25, and 26 and core buildup for teeth #'s 22, 23, 24, 25, 26, 27 and 28.

You asked the Plan to pre-approve crowns (D2740) and core buildup (D2950) for teeth #'s 22, 23, 24, 25, 26, 27 and 28. You say that you need the crowns to be able to eat and chew properly. You say you cannot eat and chew properly with worn out teeth. The Plan says that the criteria for coverage have not been met.

We decided that the Plan has to pre-approve crowns (D2740) for teeth #'s 27 and 28. 

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 crowns for teeth #'s 27 and 28. Our reviewer says that crowns (D2740) are medically reasonable and necessary for teeth #'s 27 and 28. Our physician reviewer found there is severe wear on teeth #27 and #28, and there is a lot of natural tooth structure missing. Wear on the teeth due to bruxism is a type of trauma to the teeth and when the teeth are worn severely, crowns are recommended to restore the teeth to cover areas of the teeth that can be sensitive and cause discomfort when a patient eats.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of crowns for teeth #'s 27 and 28 have been met. Therefore, we decided that the Plan has to pre-approve crowns (D2740) for teeth #'s 27 and 28.

We also decided that the Plan does not have to pre-approve crowns for teeth #'s 22, 23, 24, 25 and 26 and core buildup for teeth #'s 22, 23, 24, 25, 26, 27 and 28.

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 crowns for teeth #'s 22, 23, 24, 25 and 26 and core buildup for teeth #'s 22, 23, 24, 25, 26, 27 and 28. Our reviewer says that the request is not medically necessary. Our physician reviewer found there is a moderate amount of wear on teeth #'s 22, 23, 24, 25, and 26. Teeth #'s 22 and 23 have most of the crowns still intact, and do not need crowns on them. There may be other treatment options that can restore these teeth without removing the natural tooth structure which may cause other issues in the future for you. Core buildup is not medically necessary for teeth #'s 27 and 28 as there is enough remaining tooth structure of these teeth to retain crowns on these teeth. Core buildups are used to build up a tooth with a lot of missing tooth structure so that a crown can be placed and retained. After preparing these teeth for crowns, there will not be a need for the core buildups as there would not be any space to place the buildups. Core buildup (D2950) is also not medically reasonable or necessary for teeth #'s 22, 23, 24, 25 and 26 because this code is associated with a crown procedure, and crowns are not medically necessary for these teeth. There are more conservative treatment options for restoring teeth with wear from bruxism.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of crowns for teeth #'s 22, 23, 24, 25 and 26 and core buildup for teeth #'s 22, 23, 24, 25, 26, 27 and 28 have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for teeth #'s 22, 23, 24, 25 and 26 and core (D2950) buildup for teeth #'s 22, 23, 24, 25, 26, 27 and 28.

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.