Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for core buildup, including any pins when required (D2950) for teeth 
numbers 21 and 28, and a ceramic/porcelain crown (D2740) for teeth 21 and 29. We decided that the Plan 
does not have to pay for core buildup, including any pins when required (D2950) for tooth number 29.  
 
You asked the Plan to pay for core buildup, including any pins when required (D2950) for teeth numbers 21, 28 
and 29 and a ceramic/porcelain crown (D2740) for teeth 21 and 29 provided on January 11, 2023. You say that 
you called and you were assured this procedure would be covered under the Plan. The Plan says that the 
services remain denied due to clinical requirements not being met. 
 
We decided that the Plan has to pay for core buildup, including any pins when required (D2950) for 
teeth numbers 21 and 28, and a ceramic/porcelain crown (D2740) for teeth 21 and 29.  
  
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 core buildup, 
including any pins when required (D2950) and a ceramic/porcelain crown (D2740) 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 pay for core buildup, including any pins when 
required (D2950) for teeth 21, 28 and 29 and a ceramic/porcelain crown (D2740) for teeth 21 and 29. Our 
reviewer says core buildup, including any pins when required (D2950) for teeth 21 and 28 and a 
ceramic/porcelain crown (D2740) for teeth 21 and 29 is medically necessary. Our physician reviewer found 
that there are fracture lines and the top of the tooth 21 is broken. There is also decay noted around the filling. 
Therefore, the requested services are medically necessary as the decay needs to be removed, and the tooth 
needs a full coverage crown to prevent the tooth of fracturing more. Our physician reviewer also found that 
there is a large fracture on the tongue side of tooth 28. The core buildup is beneficial and medically necessary 
for this enrollee due to decay that needs to be removed and so much natural tooth structure has been 
compromised. Our physician reviewer also found that for tooth 29, the clinical notes state the tooth had decay 
on the cheek side of the tooth. Due to the decay noted around the crown, it would be medically reasonable and 
necessary to replace the crown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan rules for coverage of core buildup, including any pins when required (D2950) for teeth 21 and 29 and 
a ceramic/porcelain crown (D2740) for teeth 21 and 29 have been met. Therefore, we decided that the Plan has 
to pay for core buildup, including any pins when required (D2950) for teeth numbers 21 and 28, and a 
ceramic/porcelain crown (D2740) for teeth 21 and 29.  
 
We also decided that the Plan does not have to pay for core buildup, including any pins when required 
(D2950) for tooth number 29. 
 
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 core buildup, 
including any pins when required (D2950) and a ceramic/porcelain crown (D2740) 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 pay for core buildup, including any pins when 
required (D2950) for tooth number 29. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found that core buildup for tooth number 29 is not medically necessary due to lack of 
information.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of core buildup, including any pins when required (D2950) for tooth number 29 
have not been met. Therefore, we decided that the Plan does not have to pay for core buildup, including any 
pins when required (D2950) for tooth number 29. 
 
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.