Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve prefabricated abutment  includes modification and 
placement tooth #'s 4 and 29 (D6056), abutment supported porcelain/ceramic crown tooth #'s 4, 12 and 
29 (D6058), surgical placement of implant body: endosteal implant tooth #'s 4 and 29 (D6010). We 
decided that the Plan does not have to pre-approve surgical placement of mini implant tooth #12 (D6013).  
 
You asked the Plan to pre-approve prefabricated abutment  includes modification and placement tooth #'s 4 
and 29 (D6056), abutment supported porcelain/ceramic crown tooth #'s 4, 12 and 29 (D6058), surgical 
placement of implant body: endosteal implant tooth #'s 4 and 29 (D6010), and surgical placement of mini 
implant tooth #12 (D6013). You say that due to extreme gag reflex, the enrollee is not able to tolerate an 
appliance in her mouth. The only option to restore teeth for the patient would the implants as requested. The 
Plan says that the enrollee must have at least eight (8) permanent back teeth that bite together. The records that 
were sent in show the enrollee has less than this amount. 
 
We decided that the Plan has to pre-approve prefabricated abutment  includes modification and 
placement tooth #'s 4 and 29 (D6056), abutment supported porcelain/ceramic crown tooth #'s 4, 12 and 
29 (D6058), surgical placement of implant body: endosteal implant tooth #'s 4 and 29 (D6010).  
 
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 represented by codes 
D6056, D6058, and D6010. Our reviewer says that the services are medically necessary Our physician 
reviewer found the documentation indicates that due to the multiple missing teeth in both arches the patient 
does not have adequate masticatory function. Due to the documented fact that the patient has a very active gag 
reflex removable appliances are not indicated. Restoring the missing teeth via implant placement is medically 
reasonable and necessary to provide good masticatory function.   
 
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 represented by codes D6056, D6058, and D6010 have been 
met.  Therefore, we decided that the Plan has to pre-approve prefabricated abutment  includes modification and 
placement tooth #'s 4 and 29 (D6056), abutment supported porcelain/ceramic crown tooth #'s 4, 12 and 29 
(D6058), surgical placement of implant body: endosteal implant tooth #'s 4 and 29 (D6010).  
 
We also decided that the Plan does not have to pre-approve surgical placement of mini implant tooth #12 
(D6013). 
 
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 of surgical placement of mini 
implant tooth D6013 is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve the surgical placement of mini implant tooth D6013. 
 
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.