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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. . This benefit 
includes prefabricated abutment  includes modification and placement (D6056) and abutment supported 
porcelain/ceramic crown (D6058) but is limited to 2 every calendar year, 1 per tooth every 5 calendar years. 
This benefit also includes surgical placement of implant body: endosteal implant (D6010) but is limited to 2 
every calendar year. Post-operative periapical radiograph(s), showing placement of the implant must be taken 
and included with claim submissions for review and payment. The Plan contract also says that diagnosis of 
his/her oral condition must be completed prior to the establishment of an appropriate treatment plan.  Implants may be a covered benefit when considered appropriate, and logical treatment consistent with 
professional industry standards given the patients current oral condition and the following guidelines are met:  
 
Prefabricated/Custom Abutments (D6056, D6057): When utilized, abutments attach to an implant body, 
and provide support and retention for a crown. Custom abutments are laboratory processed and specific for 
an individual application. 
 
Implant Supported (D6065-66, D6082-88) & Abutment Supported Single Crowns (D6058-66) 
1. Abutment supported crowns are retained and supported by an abutment which connects to the 
implant. 
 
You can find this information in the Plans 2023 Benefits Coverage booklet and the National Clinical Criteria 
Guidelines and Practice Parameters, which is available on the Plans website. 
 
This benefit also includes coverage for routine preventive dental from a network provider. Limitations include 
oral exams are limited to 2 per calendar year, routine cleanings are limited to 2 per calendar year, fluoride 
treatments are limited to 2 per calendar year, bitewing x-rays are limited to twice in any calendar year, and full 
mouth x-rays are limited to once every 36 months. Surgical placement of mini implant tooth #12 (D6013) is not 
listed as covered under the Plans dental benefit. For claims, eligibility and benefit questions call the Plan's 
Dental Plan customer service number noted in the Evidence of Coverage. You can find this information on 
pages 64-65 of the Plans 2023 EOC.