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 in an outpatient setting when an excluded service is the primary procedure involved, it is not
covered regardless of its complexity or difficulty. An alveoloplasty and a frenectomy are excluded from
coverage when either of these procedures is performed in connection with an excluded service: e.g. the noncovered
extraction or the preparation of the mouth for dentures. The following are non-covered services:
The extraction of an impacted tooth, an alveoloplasty, (the surgical improvement of the shape and condition of
the alveolar process), when performed for the preparation of the mouth for dentures, Frenectomy when
performed for the preparation of the mouth for dentures, Extractions that are due to decay or periodontal
disease, Extractions done for the purpose of obtaining dentures, and Services related to chronic dental disease
(i.e., gingivectomy). Also, non-covered is the removal of a benign growth or radicular cyst, in the mouth, or
from structures directly supporting the teeth means the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum, and alveolar process). Insertion of metallic implants
used for enhancement of the structure of the jaws in order to support dentures or prosthesis. Excision of torus
mandibularis or excision of a maxillary torus palatinus is usually performed to accommodate a denture. The
removal of the torus palatinus (a bony protuberance of the hard palate) and torus mandibularis could be a
covered service. However, with rare exception, this surgery is performed in connection with an excluded
service, i.e., the preparation of the mouth for dentures. Under such circumstances, reimbursement is not made
for this purpose. The rules say that covered services include the following: Surgery related to the jaw or any
structure connected to the jaw including structures of the facial area below the eyes, for example (mandible,
teeth, gums, tongue, palate, salivary glands, sinuses, etc.). Wiring of the teeth when performed in connection
with the reduction of a jaw fracture. Reduction of any fracture of the jaw or any facial bone, including dental
splints or other appliances, if used for this purpose. Reconstruction of a ridge if performed as a result of and at
the same time as the surgical removal of a tumor (the total surgical procedure is covered). Removal of a torus
palatinus (a bony protuberance of the hard palate) may be covered, if the procedure is not performed to prepare
the mouth for dentures. Extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease.
Insertion of metallic implants if the implants are used to assist in or enhance the retention of a dental prosthetic
as a result of a covered service. The extraction of teeth to prepare the jaw for radiation treatments of neoplastic
disease is also covered. This is an exception to the requirement that to be covered, a non-covered procedure or
service performed by a dentist must be an incident to and integral part of a covered procedure or service
performed by the dentist. Whether such services as the administration of anesthesia, diagnostic x-rays, and
other related procedures are covered depends upon whether the primary procedure being performed by the
dentist is itself covered.
Thus, an x-ray taken in connection with the reduction of a fracture of the jaw or facial bone is covered.
However, a single x-ray or x-ray survey taken in connection with the care or treatment of teeth or the
periodontium is not covered. You can find this in the Local Coverage Determination (LCD) Dental Services
(L34574).
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 certain dental services as a supplemental (extra) benefit. The Plan
contract says that in general, preventive dental services (such as cleaning, routine dental exams, and
dental X-rays) are not covered by Original Medicare. However, we provide a Dental Allowance to reimburse
selected supplemental preventive and comprehensive dental services. Unused balance of the allowance
amount does not carry forward to future benefit years. Cosmetic procedures are not covered. Your dental
provider will submit a claim for reimbursement. You can use any licensed dental provider who has not opted
out of Medicare and is not on the preclusion or exclusion list. There is a $1,500 combined allowance for
supplemental preventive and comprehensive dental services every year. Member is responsible for any amount
over and above the allowance amount. You can find this information on page 42 of the Plan's 2021 Evidence of
Coverage.