Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the surgical removal of an erupted tooth (D7210) for tooth #21, 
#28, #29, and #31. We decided that the Plan does not have to pre-approve the surgical removal of an erupted 
tooth (D7210) for tooth #3, #7, #8, #9, #10, #13, #14, #23, #24, #25, and #26.  
 
You asked the Plan to pre-approve the surgical removal of an erupted tooth (D7210) for tooth #3, #7, #8, #9, 
#10, #13, #14, #21, #23, #24, #25, #26, #28, #29, and #31. You say that you are appealing the down coding. 
The Plan says that the down coding for the requested teeth is correct, because the records support the 
extractions to be accurately represented by code D7140. 
 
We decided that the Plan has to pre-approve the surgical removal of an erupted tooth (D7210) for tooth 
#21, #28, #29, and #31.  
 
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 surgical 
removal of an erupted tooth (D7210) for tooth #3, #7, #8, #9, #10, #13, #14, #21, #23, #24, #25, #26, #28, #29, 
and #31 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 item/service at issue. Our reviewer 
says that the surgical removal of an erupted tooth (D7210) for tooth #21, #28, #29, and #31 is medically 
necessary. Our physician reviewer found that the teeth for #21, #28, #29, and #31 may require bone removal.  
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve the surgical removal of an erupted tooth (D7210) for tooth #21, #28, #29, and #31.  
 
We also decided that the Plan does not have to pre-approve the surgical removal of an erupted tooth 
(D7210) for tooth #3, #7, #8, #9, #10, #13, #14, #23, #24, #25, and #26. 
 
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 surgical 
removal of an erupted tooth (D7210) for tooth #3, #7, #8, #9, #10, #13, #14, #21, #23, #24, #25, #26, #28, #29, 
and #31 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 item/service at issue. Our reviewer 
says that the surgical removal of an erupted tooth (D7210) for tooth #3, #7, #8, #9, #10, #13, #14, #23, #24, 
#25, and #26 is not medically necessary. Our physician reviewer found the documentation indicates that the 
following teeth do not appear to require bone removal for extraction and can be removed via elevation and/or 
forceps removal for teeth #3, #7, #8, #9, #10, #13, #14, #23, #24, #25, and #26. Therefore, the down grade 
from the surgical removal of an erupted tooth (D7210) to and extraction (D7140) is upheld for teeth #3, #7, #8, 
#9, #10, #13, #14, #23, #24, #25, and #26.  
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the surgical removal of an erupted tooth (D7210) for tooth #3, #7, #8, #9, #10, 
#13, #14, #23, #24, #25, and #26. 
 
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.