Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planning (D4341) of the UL 
quadrant. We decided that the Plan does not have to pre-approve periodontal scaling and root planning 
(D4341 x 3) of the UR, LR and LL quadrants.  
 
You asked the Plan to pre-approve periodontal scaling and root planning (D4341 x 4). You say that you are 
appealing with supporting records. The Plan says that the criteria for coverage have not been met. 
 We decided that the Plan has to pre-approve periodontal scaling and root planning (D4341) of the UL 
quadrant.  
 
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 when the services are medically necessary and reasonable. The Plans rule for coverage states that 
your tooth must have noticeable bone loss or show on an x-ray that there is a hard substance built up on the 
root of the tooth. 
 
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 dental services. Our reviewer says 
that the request is medically necessary for the UL quadrant. Our physician reviewer found that teeth numbers 
10, 14, 15 and 16 have apparent loss of bone and would qualify for the D4341 procedure on the UL quadrant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve periodontal scaling and root planning (D4341) of the UL quadrant.  
 
We also decided that the Plan does not have to pre-approve periodontal scaling and root planning 
(D4341 x 3) of the UR, LR and LL quadrants. 
 
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 when the services are medically necessary and reasonable. The Plans rule for coverage states that 
your tooth must have noticeable bone loss or show on an x-ray that there is a hard substance built up on the 
root of the tooth. 
 
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 periodontal scaling and root planning 
(D4341 x 3) of UR, LR and LL quadrants. Our reviewer says that the request is not medically necessary for the 
UR, LR and LL quadrants. Our physician reviewer found that the UR, LR and LL quadrants to not clearly 
show bone loss on four or more teeth. There are less than four teeth in the UR, LR and LL quadrants. Where 
there are 1-3 teeth in any quadrant that exhibit bone loss there is a separate more appropriate code that can be 
applied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of periodontal scaling and root planning (D4341 x 3) of the UR, LR and LL 
quadrants have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planning (D4341 x 3) of the UR, LR and LL quadrants. 
 
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.