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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. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for the removal of residual tooth roots (cutting procedure) (D7250) every 12 to 60 months or per 
lifetime, depending on type of service.  
 
Removal of residual tooth roots is a surgical procedure used to remove tooth root structure that remains at or 
below the level of crestal bone following an unsuccessful extraction attempt leaving a fractured root in bone; 
and it involves cutting of soft tissue and bone, removal of tooth structure, and closure. This procedure/service 
includes the administration of local anesthesia, suturing if required, and routine post-operative 
care).Policy/Criteria 
It is the policy of the Plans dental benefits  that removal of residual roots is medically necessary 
when the following conditions are met: 
A. When tooth roots or fragments of tooth roots remain in bone following a previous incomplete tooth  
      extraction by another provider or provider group; 
 B. When none of the following contraindications apply: 
    1. When the removal of residual tooth root(s) is performed by the same provider or 
         within the same provider group that attempted the original failed extraction; 
    2. When a conservative non-surgical procedure is possible; 
C. Required documentation to support medical necessity include the following: 
    1. Clinical chart/treatment notes documenting medical necessity for the residual root removal;  
    2. A current (within the past six months) diagnostic-quality panoramic or periapical radiograph showing the  
        entire residual tooth root; 
    3. Any forms required by state law or regulations. 
 
You can find this information on page 65 of the Plans 2023 Evidence of Coverage (EOC), and in the Plans 
Clinical Reference Guide. 
 
Summary of Criteria: Citation(s): Social Security Act, Section 1862(a)1(A). 
Summary of Citation(s): CMS has not issued specific coverage criteria in the form of an LCD (Local Coverage 
Determination) or NCD (National Coverage Determination) for this particular item or service. However, per 
Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), Medicare does not pay for any items or 
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. The determination of medical necessity must be tailored to the 
individual patient and their unique clinical scenario. CMS considers services to be medically reasonable and 
necessary if they are: 
 
 Safe and effective; 
 Not mainly for the convenience of the patient or the physician; 
 Not experimental or investigational; and 
 Appropriate, including the duration and frequency that is considered appropriate for the service, in  
   terms of whether it is: 
   - Furnished in accordance with accepted standards of medical practice for the diagnosis or    
      treatment of the patient's condition or to improve the function of a malformed body member; 
   - Furnished in a setting appropriate to the patient's medical needs and condition; 
   - Ordered and furnished by qualified personnel; 
   - One that meets, but does not exceed, the patient's medical need; and 
   - At least as beneficial as an existing and available medically appropriate alternative. 
 
You can find this rule in the Medicare Program Integrity Manual, Chapter 13, Section 13.5.4