Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), abutment supported retainer for porcelain/ceramic (D6068), custom fabricated abutment  includes 
placement (D6057), bone replacement graft for ridge preservation - per site (D7953) and guided tissue 
regeneration  non-resorbable barrier, per implant (D6107). 
 
You asked the Plan to pre-approve dental services represented by codes D6010, D6068, D6057, D7953, and 
D6107. You say that you are going to have two missing teeth after the extraction. You also say that you have 
been doing fine for year with your five molars and your long term goal is to replace all your molars. Tooth #13 
is not present, and there is a bridge that anchors teeth #12, 14, with a fake tooth that is connected to the 
anchoring teeth.  The Plan denied your request. The Plan says you must have at least eight (8) permanent back 
teeth that bite together. Your records that were sent in show you have less than this amount.  
 
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 dental 
services represented by codes D6010, D6057, D6068 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 dental services represented by codes 
D6010, D6057, D6068. Our reviewer says that the dental services are not medically necessary. Our physician 
reviewer found included was a clinical note regarding the condition of teeth #12-14 area, a panoramic x-ray, 
and bitewing and periapical radiographs dated August 8, 2023. The bitewing radiograph of the left side of the 
mouth shows that tooth #12 is fractured at the root, making the bridge non-restorable. There is moderate to 
severe bone loss around #14. The Plan is stating that they will approve crowns on teeth #12 and #13, but #12 is 
non-restorable due to the fracture of the root. A crown cannot be placed on a tooth in this condition. A crown 
on tooth #13 would also not be possible as tooth #13 is not present in the mouth. A crown can only be placed 
on a tooth that has enough tooth structure to support a crown, which tooth #12 and #13 do not have. You are in 
need for replacement of teeth in this area. The bridge will need to be removed for the extraction and once 
bridge removal is complete along with extraction of tooth #12, you will be missing. An alternative treatment 
option is to replace the teeth with a partial denture which would replace the missing teeth and also help you to 
eat. Based on the information provided D6010 teeth #'s 12, 13, D6057 tooth #12, and D6068 teeth #'s 12, 13 
are not medically  necessary 
 
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 dental services represented by codes D6010, D6057, D6068 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body: 
endosteal implant (D6010), abutment supported retainer for porcelain/ceramic (D6068), custom fabricated 
abutment  includes placement (D6057).  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6010 and D6057 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
approve bone replacement graft for ridge preservation - per site (D7953) and guided tissue regeneration  non-
resorbable barrier, per implant (D6107)