Appeal type: unknown
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. 
 
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 
coverage for the surgical placement of implant body: endosteal implant (D6010) and code D6013, but coverage 
of these codes is limited to 2 every calendar year. You can find this information on page 115 of the Plan's 2023 
Evidence of Coverage 
 
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 
coverage of abutment supported porcelain/ceramic crown (D6058) and other codes within the range of D6058-
D6075, D6082-D6088, D6097-D6099, D6121-D6123, and D6194. Coverage of codes within these ranges is 
limited to 2 every calendar year; 1 per tooth every 5 calendar years. You can find this information on page 115 
of the Plan's 2023 Evidence of Coverage (EOC.)  
 
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 
coverage for retainer crowns - porcelain/ceramic (D6740), pontics - porcelain/ceramic (D6245), crowns - 
porcelain/ceramic (D2740), and other codes within the range of D2710-D2792 and D6210-D6792. Coverage of 
codes within these ranges is limited to 3 every calendar year; 1 per tooth every 5 calendar years. You can find 
this information on pages 109, and 119-120. 
 
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 
coverage for core buildup, including any pins when required (D2950), prefabricated post and core in addition 
to crown (D2954), and other codes within the range of D2950-D2954. Coverage of codes within this range is 
limited to 3 every calendar year; 1 per tooth every 5 calendar years. You can find this information on page 110 
of the Plan's 2023 EOC. 
 
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 
coverage for endodontic therapy, anterior tooth (D3310) twice per calendar year and once per tooth in a 
lifetime. You can find this information on page 111 of the Plan's 2023 EOC. 
 
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 
coverage for bone graft at time of implant placement (D6104) twice every calendar year. You can find this 
information on page 118 of the Plan's 2023 Evidence of Coverage. 
  
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 also includes 
coverage for specific dental procedure codes listed in the Plan's 2023 Schedule of Benefits booklet. If a service 
is not listed, it is not covered. Codes D0171, D4265, D9610, D7953, and D6973 are not listed as covered 
procedure codes. You can find this information on pages 105-124 of the Plan's 2023 EOC.