Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periodontal disease. 
Treatment: Planing and scaling 4 quadrants. 

The insurer denied coverage for Planing and scaling 4 quadrants. 

The denial is upheld. 
 
The patient is an adult, with a history of periodontal disease, gastro-esophageal reflux disease (GERD), obesity, asthma, endometriosis, fibromyalgia, migraines, and irritable bowel syndrome (IBS). The patient presented to the dentist and an x-ray was taken. The American Dental Association (ADA) CDT 2023 Dental Procedure Code book gives the correct terminology for "deep gum and root cleaning." It is "D4341 - Periodontal scaling and root planing four or more teeth per quadrant." 

The patient requested coverage for D4341 - scaling and root planing, upper right quadrant, D4341 - scaling and root planing, lower right quadrant, D4341 - scaling and root planing, lower left quadrant, and D4341 - scaling and root planing, upper left quadrant. 

An appeal letter from the patient, states "I experience the following dental problems: painful bleeding gums, aching and wiggling teeth, recurrent infections and lesions." These symptoms may or may not be due to active periodontal disease that would be appropriately treated with scaling and root planing. As these symptoms may indicate active periodontal disease, a current thorough periodontal examination record is essential for diagnosis and treatment planning. As such a record is not present, necessity of the requested treatment cannot be determined. 

X-rays from the Plan were received in an undated panoramic radiograph and were reviewed. This shows some horizontal radiographic bone loss, as the gingival crest is generally several millimeters away from the Cemento-Enamel Junction (CEJ) around the upper right molars that lack opposing teeth on the lower arch. Dental calculus is not evident in the radiograph. 

A document - Authorization Determination, gives the reason for the denial of the requested treatment as, "no evidence of significant bone loss" and "documentation did not meet the clinical criteria." 

An ADA Claim Form states that periodontal charting and x-rays are attached to the claim. However, no periodontal charting was received. the radiographs received do not confirm the necessity of scaling and root planning on the upper and lower quadrants. 

Without periodontal charting and a clinical narrative, there is no indication of the presence of active periodontal disease, it is not possible to determine the diagnosis. Without a diagnosis, it is not possible to determine if surgical or non-surgical periodontal treatment is indicated. 

No documentation supporting that the patient has active disease, has been received. 

Without periodontal charting and a clinical narrative, there is no indication of the presence of active periodontal disease, it is not possible to determine a diagnosis. Without a diagnosis, it is not possible to determine which periodontal or oral hygiene treatment and follow up treatment is appropriate. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D4341, deep gum and root cleaning, upper right part of mouth, D4341 deep gum and root cleaning, lower right part of mouth, D4341 deep gum and root cleaning, lower left part of mouth, and D4341 deep gum and root cleaning, upper left part of mouth is not substantiated.