Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of erupted tooth requiring removal 
of bone (D7210 x13) on teeth #s 2, 6, 7, 8, 9, 10, 11, 15, 18, 19, 21, 22, and 31), the surgical removal of 
residual tooth roots (D7250), the buccal/labial frenectomy (D7961), the alveoloplasty in conjunction with 
extractions (D7310 x4), the deep sedation, first 15 minutes (D9222), and the deep sedation, each subsequent 15 
minute increment (D9223 x4), the limited oral evaluation (D0140) and the therapeutic parental drugs (D9612). 
 
You asked the Plan to pre-approve the surgical removal of erupted tooth requiring removal of bone (D7210 
x13) on teeth #s 2, 6, 7, 8, 9, 10, 11, 15, 18, 19, 21, 22, and 31), the surgical removal of residual tooth roots 
(D7250), the buccal/labial frenectomy (D7961), the alveoloplasty in conjunction with extractions (D7310 x4), 
the deep sedation, first 15 minutes (D9222), and the deep sedation, each subsequent 15 minute increment 
(D9223 x4), the limited oral evaluation (D0140) and the therapeutic parental drugs (D9612). You say that you 
need this anesthetic is because your teeth crumbles. You say you cannot imagine having all this work done 
without anesthesia. The Plan denied your request. The Plan says the codes for D7210 x13, D7250, D7961, 
D7310 x4, D9222, and D9223 are not medically necessary. The Plan says the benefit has been exhausted for 
code D0140 and code D9612 is not a covered benefit. 
 
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 
removal of erupted tooth requiring removal of bone (D7210 x13) on teeth #s 2, 6, 7, 8, 9, 10, 11, 15, 18, 19, 21, 
22, and 31), the surgical removal of residual tooth roots (D7250), the buccal/labial frenectomy (D7961), the 
alveoloplasty in conjunction with extractions (D7310 x4), the deep sedation, first 15 minutes (D9222), and the 
deep sedation, each subsequent 15 minute increment (D9223 x4) 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 removal of erupted tooth 
requiring removal of bone (D7210 x13) on teeth #s 2, 6, 7, 8, 9, 10, 11, 15, 18, 19, 21, 22, and 31), the surgical 
removal of residual tooth roots (D7250), the buccal/labial frenectomy (D7961), the alveoloplasty in 
conjunction with extractions (D7310 x4), the deep sedation, first 15 minutes (D9222), and the deep sedation, 
each subsequent 15 minute increment (D9223 x4). Our reviewer says that the services are not medically 
necessary. Our physician reviewer found there was a panoramic x-ray included that was very dark. The x-ray is 
unreadable, and diagnoses cannot be made from the x-ray. Based on the information submitted, the requested 
treatment is not medically necessary as they were unable to be verified with the x-ray due to poor quality. 
 
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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation (D0140) was exhausted on date of service August 10, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the therapeutic parental drugs (D9612) 
is not among those covered under this benefit. 
 
 
 
 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 removal of erupted tooth requiring removal of bone (D7210 x13) 
on teeth #s 2, 6, 7, 8, 9, 10, 11, 15, 18, 19, 21, 22, and 31), the surgical removal of residual tooth roots (D7250), 
the buccal/labial frenectomy (D7961), the alveoloplasty in conjunction with extractions (D7310 x4), the deep 
sedation, first 15 minutes (D9222), and the deep sedation, each subsequent 15 minute increment (D9223 x4), 
the limited oral evaluation (D0140) and the therapeutic parental drugs (D9612) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the surgical removal of erupted tooth requiring removal 
of bone (D7210 x13) on teeth #s 2, 6, 7, 8, 9, 10, 11, 15, 18, 19, 21, 22, and 31), the surgical removal of 
residual tooth roots (D7250), the buccal/labial frenectomy (D7961), the alveoloplasty in conjunction with 
extractions (D7310 x4), the deep sedation, first 15 minutes (D9222), and the deep sedation, each subsequent 15 
minute increment (D9223 x4), the limited oral evaluation (D0140) and the therapeutic parental drugs (D9612).