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Decision: unknown

 
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. 
 
The rules say that treatment for temporomandibular joint (TMJ) syndrome may be covered when the actual 
condition or symptom is medical in nature and the services provided are reasonable and necessary for the 
diagnosis and/or treatment of a medical illness or injury. You can find these rules in the Medicare Benefit 
Policy Manual, Chapter 15, Section 150.1. 
 
The rules say that Medicare does not pay for dentures (false teeth). The rules say that Medicare does not pay 
for surgery or treatment to prepare the mouth for dentures. There is only one exception to the noncoverage rule 
for dentures. Medicare will pay for dentures that are a portion of or an integral part of a Medicare-covered 
prosthesis such as an obturator that fills an opening in the palate. You can find this rule in the Medicare Benefit 
Policy Manual, Chapter 15, Sections 120(3)(C) and Chapter 16, Section 140. 
 
The rules say that Medicare will pay for normally excluded dental services or related services in limited cases. 
Medicare will pay for this non-routine dental care:  An excluded dental service if it is performed by a dentist 
as incident to and as an integral part of a covered service performed by the same dentist on the same day. This 
exception does not apply if the excluded service is the primary service performed by the dentist.  Services for 
wiring of the teeth if done in connection with a jaw fracture.  A dental examination done in the hospital if it is 
part of a work-up prior to kidney transplant surgery.  Services for extraction of the teeth if done to prepare the 
jaw for radiation treatment needed as a result of cancer. You can find these rules in the Medicare Benefit Policy 
Manual, Chapter 15, Section 150 and Chapter 16, Section 140 and in the National Coverage Determinations 
Manual, Chapter 1, Section 260.6. 
 
  The rules say that Medicare will pay for normally excluded dental services or related services in limited cases. 
Medicare will pay for inpatient hospital services furnished in connection with an excluded dental service if a 
hospital stay is needed because of the persons underlying medical condition or because of the complexity of 
the dental service. Medicare will pay for the inpatient hospital services but will not pay for the services of 
physicians furnished in connection with the excluded dental services. You can find these rules in the Medicare 
Benefit Policy Manual, Chapter 1, Section 70. 
 
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. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
preventive and comprehensive dental services along with specific dental codes that are listed on the dental 
benefit chart. The non-autogenous connective tissue graft is not covered by the Plan's dental benefits. You can 
find this information on pages 283 to 299 of the Plans 2023 Evidence of Coverage (EOC). 
 
The contract also says that gingivectomy, excision gingiva, each quadrant procedures require prior 
authorization under cosmetic, reconstructive surgery rule. You can find this information on pages 1 to 12 of the 
Plan's 2023 Health Medical Policy.