Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the surgical placement of implant body (D6010), the 
prefabricated abutment (D6056), and the abutment supported to a crown (D6058) for tooth #10. We 
decided that the Plan does not have to pre-approve the bone replacement graft (D7953) for tooth #10.  
 
You asked the Plan to pre-approve the surgical placement of implant body (D6010), the prefabricated abutment 
(D6056), the abutment supported to a crown (D6058), and the bone replacement graft (D7953) for tooth #10.. 
You say that the implant is medically necessary. The Plan says that the denial of authorization for the surgical 
placement of implant body, the prefabricated abutment, the abutment supported to a crown is correct, because 
there was no panoramic or full mouth series of x-rays to determine the treatment plan. Also, the bone 
replacement graft is not covered by the Plan. 
 
We decided that the Plan has to pre-approve the surgical placement of implant body (D6010), the 
prefabricated abutment (D6056), and the abutment supported to a crown (D6058) for tooth #10.  
 
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 surgical 
placement of implant body, the prefabricated abutment, and the abutment supported to a 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 implant body 
(D6010), the prefabricated abutment (D6056), and the abutment supported to a crown (D6058) for tooth #10. 
Our reviewer says that the surgical placement of implant body, the prefabricated abutment, and the abutment 
supported to a crown for tooth #10 would be considered medically necessary and reasonable. Our physician 
reviewer found that the broken tooth #10 would reasonable be replaced by a single tooth implant as the 
adjacent teeth had been crown previously. The other tooth in the upper arch is missing tooth #4 and was noted 
as having insufficient space to restore. The replacement of the single lateral incisor appears to be appropriate. 
 
The Plan requires that the entire treatment plan be reviewed prior to approval of any implant placement. In this 
case the provider did indicate the overall treatment plan with an additional letter of necessity. The integrity of 
the upper arch would be maintained, but for tooth #4 which has insufficient space if an implant were placed in 
the tooth #10 area. The bone appears adequate to support an implant and the treatment plan of the implant body 
placement, abutment, and crown would be reasonable and meet the Plan's criteria.  
 
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 implant body (D6010), the prefabricated abutment 
(D6056), the abutment supported to a crown (D6058) for tooth #10 have been met. Therefore, we decided that 
the Plan has to pre-approve the surgical placement of implant body (D6010), the prefabricated abutment 
(D6056), and the abutment supported to a crown (D6058) for tooth #10.  
 
We also decided that the Plan does not have to pre-approve the bone replacement graft (D7953) for tooth 
#10. 
 
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 bone replacement graft is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
bone replacement graft (D7953) for tooth #10. 
 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.