Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bridge retainer crown (D6740) on teeth #s 3, 6, 11, 
and 13, the bridge replacement tooth (D6245) for teeth #s 4, 5, and 12, the tooth colored crown (D2740) for 
teeth #s 7, 8, 9, 10, and 31, and the core build-up (D2950) for teeth #s 7, 8, 9, 10, 31, 3, 6, 11, and 13.  
 
You asked the Plan to pre-approve the bridge retainer crown (D6740) on teeth #s 3, 6, 11, and 13, the bridge 
replacement tooth (D6245) for teeth #s 4, 5, and 12, the tooth colored crown (D2740) for teeth #s 7, 8, 9, 10, and 31, and the core build-up (D2950) for teeth #s 7, 8, 9, 10, 31, 3, 6, 11, and 13.  You say that your dentist is 
recommending crowns for multiple top and bottom teeth to prevent further damage. You say there is enough 
tooth and structure for crowns to be installed. The Plan denied your request. The Plan says the services are not 
medically necessary. The Plan says D6245 and D6740 are denied because if there are missing teeth on both 
sides of the arch, and the benefit of a fixed bridge in that same arch is limited to the benefit of a partial denture. 
The Plan says D2740 is not covered for 'wear and tear.' The Plan says D2950 is denied because it is secondary 
to a primary denied procedure.  
 
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 bridge 
retainer crown (D6740) on teeth #s 3, 6, 11, and 13, the bridge replacement tooth (D6245) for teeth #s 4, 5, and 
12, the tooth colored crown (D2740) for teeth #s 7, 8, 9, 10, and 31, and the core build-up (D2950) for teeth #s 
7, 8, 9, 10, 31, 3, 6, 11, and 13 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 bridge retainer crown (D6740) on 
teeth #s 3, 6, 11, and 13, the bridge replacement tooth (D6245) for teeth #s 4, 5, and 12, the tooth colored 
crown (D2740) for teeth #s 7, 8, 9, 10, and 31, and the core build-up (D2950) for teeth #s 7, 8, 9, 10, 31, 3, 6, 
11, and 13. . Our reviewer says that the dental services are not medically necessary. Our physician reviewer 
found the documentation provided was not sufficient to decide of medical necessity and/or meeting the criteria 
for coverage for these services. The radiographs provided were not of diagnostic quality and there was no 
narrative indicating the reason for need for these services. 
 
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 bridge retainer crown (D6740) on teeth #s 3, 6, 11, and 13, the bridge 
replacement tooth (D6245) for teeth #s 4, 5, and 12, the tooth colored crown (D2740) for teeth #s 7, 8, 9, 10, 
and 31, and the core build-up (D2950) for teeth #s 7, 8, 9, 10, 31, 3, 6, 11, and 13.  have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the bridge retainer crown (D6740) on teeth #s 
3, 6, 11, and 13, the bridge replacement tooth (D6245) for teeth #s 4, 5, and 12, the tooth colored crown 
(D2740) for teeth #s 7, 8, 9, 10, and 31, and the core build-up (D2950) for teeth #s 7, 8, 9, 10, 31, 3, 6, 11, and 
13.