Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The rules say
that CLINICAL DENTISTRY GUIDELINES 2020 excerpts: For endodontic treatment (Codes D3310 -
D3330), documentation is required that shows the treatment is medically necessary (i.e., tooth is broken,
decayed or previously restored, functional with an unhealthy nerve and more than 50% of the tooth structure is
sound) and the tooth has a good endodontic, periodontal and/or restorative prognosis. RESTORATIVE
TREATMENTS: A. Restorative procedures for teeth exhibiting a poor prognosis due to gross carious
destruction of the clinical crown at/or below the bone level, advanced periodontal disease, untreated periapical
pathology or poor restorability are not covered. (MMPROG_) (MMPROGR)G. Crowns - Single Restorations
Only (Codes D2712 - D2791)1. Administrative Issues a. Providers may document the date of service for these
procedures to be the date when final impressions are completed (subject to review). b. Providers must complete
any irreversible procedure started regardless of payment or coverage and only bill for indirect restorations
when the service is completed (permanently cemented). c. Crown services must be documented using valid
procedure codes in the American Dental Association's Current Dental Terminology (CDT).2. A crown may be
medically necessary when the tooth is present and: a. The tooth has evidence of decay undermining more than
50% of the tooth (making the tooth weak), when a significant fracture is identified, or when a significant
portion of the tooth has broken or is missing and has good endodontic, periodontal and/or restorative prognoses
(MM272) (MM273) (MM237R) (MM274) (MM274E) (MM275) (MM275P) and is not required due to wear
from attrition, abrasion and/or erosion (MM2LIM). b. There is a significantly defective crown (defective
margins or marginal decay) or there is recurrent decay. (MM270) c. The tooth is in functional occlusion.
(MM271) d. When anterior teeth have incisal edges/corners that are undermined or missing because of caries, a
defective restoration or are fractured off, a labial veneer may not be sufficient. The treatment of choice may be
a porcelain fused to base metal crown or a porcelain/ceramic substrate crown. (MM296) e. The tooth has a
good endodontic, periodontic and restorative prognosis with a minimum crown/root ratio of 50% and a life
expectancy of at least five years.7. Core Buildup, including any pins when required (Code D2950), must show
evidence that the tooth requires additional structure to support and retain a crown. (MM291) a. Core buildup
refers to building up of coronal structure when there is insufficient retention for an extra-coronal restorative
procedure. b. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a
preparation. You can find this information in the Guidelines and Practice
Parameters.