Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Pain.

Treatment: D0364 computed tomography (CT) scan.

The insurer denied coverage for D0364 computed tomography (CT) scan.

The denial is overturned.

This patient had tooth 30 treated with a root canal and crown years prior. The patient recently visited a dentist as tooth 30 became symptomatic. The patient complained of pain and pressure to bite. Radiographically tooth 30 has a root canal with misdirection of instrumentation that could represent perforation. No instrument separation is noted. There is a large periapical radiolucency associated with the mesial root. The dentist has recommended an apicoectomy for this symptomatic tooth and requested a cone-beam computed tomography (CBCT) before surgical management, and apicoectomy of the tooth.

The health plan acted reasonably; however, the last line of the office notes clearly states the dentist wants the CBCT for use when performing an apicoectomy.      

D0364 computed tomography (CT) scan is considered medically necessary for this patient.

This request for D0364 computed tomography (CT) scan is medically necessary and is to be used during an apicoectomy procedure of tooth 30. This is the recommended treatment to treat the radiolucencies at the apices of #30. Therefore, the request for D0364 computed tomography (CT) scan is considered medically necessary for this patient.

AMERICAN ASSOCIATION OF ENDODONTISTS. (2018), "Most clinicians agree that it is advantageous and, in some instances, essential to take a CBCT scan before any endodontic surgery. Precise imaging becomes especially important in surgical cases that might involve vulnerable structures, including sinus cavities, nerve channels, or blood vessels. CBCT scans reveal extra anatomy, relationships of structures, traumatic fractures, missed canals, resorptions, instrumentation-related issues such as perforations, and help during treatment complications. Accurate measurements can replace certain working images and thus make up for the higher radiation patients receive during a CBCT scan."

Shekhar, V., & Shashikala, K. (2013), "CBCT systems used in endodontics provide small field of view images at low dose with rapid scan time and sufficient spatial resolution. Various studies have found CBCT to be clinically superior to IOPA radiography for the detection of periapical lesions [1, 4-6, 11]. Thus, a CBCT scan may provide a safer, faster, and more accurate method for differential diagnosis of the periapical lesions. This allows the clinician to decide, based on the type of periapical lesion, whether surgery is necessary or not, without the invasive biopsy procedure and waiting to see if healing has occurred (recall period). Evaluation of a periapical lesion with CBCT changes the estimation of size and choice of treatment among endodontists compared to intraoral periapical (IOPA) radiography. Selecting the most appropriate choice of treatment using the most accurate imaging modality would ultimately reduce cost and morbidity significantly in patients undergoing endodontic therapy, and the lesion may be managed more effectively. However, scientific consensus maintains that the true nature of a periapical lesion is accurately identified by histopathology only, which is considered to be the "gold standard" for achieving final confirmatory diagnosis of periapical lesions [1, 2, 4, 12]."

Scarfe, W. C., Levin, M. D., Gane, D., & Farman, A. G. (2009), "Cone Beam Computed Tomography (CBCT) is a diagnostic imaging modality that provides high-quality, accurate three-dimensional (3D) representations of the osseous elements of the maxillofacial skeleton."

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D0364 computed tomography (CT) scan is substantiated.