Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the surgical placement of the implant body (D6010), a 
prefabricated abutment (D6056), and an abutment supported to crown (D6058) for tooth #14. We 
decided that the Plan does not have to pre-approve the dental visit (D9430).  
 
You asked the Plan to pre-approve the surgical placement of the implant body (D6010), a prefabricated 
abutment (D6056), an abutment supported to crown (D6058), a dental visit (D9430) for tooth #14.. You say 
that the requested services are medically necessary for the enrollee. The Plan says that the denial of 
authorization for the surgical placement of the implant body, a prefabricated abutment, an abutment supported 
to crown is correct because the medical necessity criteria have not been met. Also, the dental visit is not 
covered by the Plan. 
 
We decided that the Plan has to pre-approve the surgical placement of the implant body (D6010), a 
prefabricated abutment (D6056), and an abutment supported to crown (D6058) for tooth #14.  
 
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 implant 
body, a prefabricated abutment, an abutment supported to crown 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 surgical placement of the implant 
body (D6010), a prefabricated abutment (D6056), and an abutment supported to crown (D6058) for tooth #14. 
Our reviewer says that the surgical placement of the implant body, a prefabricated abutment, and an abutment 
supported to crown for tooth #14 is medically necessary. Our physician reviewer found that the documentation 
included was a panoramic x-ray. Tooth #14 is missing. Based on positioning of the teeth implant #14 would 
come into contact with tooth #20 and would meet the criteria of a tooth opposing the implant, making it a 
functional implant. Regarding the dental visit (D9430), I am unable to determine whether this code is medically 
reasonable or necessary as there were no clinical notes included.  
 
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 the implant body (D6010), a prefabricated abutment 
(D6056), and an abutment supported to crown (D6058) for tooth #14 have been met. Therefore, we decided 
that the Plan has to pre-approve the surgical placement of the implant body (D6010), a prefabricated abutment 
(D6056), and an abutment supported to crown (D6058) for tooth #14.  
 
We also decided that the Plan does not have to pre-approve the dental visit (D9430). 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental visit is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the dental visit 
(D9430). 
  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.