Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impacted tooth. 
Treatment: Extraction of impacted tooth with some bone teeth 1, 16, and 17, intravenous (IV) sedation each 15 minutes and IV sedation each 15 minutes. 

The insurer denied coverage for extraction of impacted tooth with some bone teeth 1, 16, and 17, intravenous (IV) sedation each 15 minutes and IV sedation each 15 minutes. 

The denial is upheld. 

According to the documentation submitted, this is an adult with no documented history. Coverage was requested for extraction of impacted tooth with some bone teeth 1, 16, and 17, intravenous (IV) sedation each 15 minutes and IV sedation each 15 minutes. 

The insurer has denied coverage for extraction of impacted tooth with some bone teeth 1, 16, and 17, intravenous (IV) sedation each 15 minutes and IV sedation each 15 minutes as not medically necessary. In a Final Adverse Determination letter, they stated that to approve the requested extractions the patient must have severe pain in the tooth, the tooth must be in a position that will not let it break through the gum by itself, and the gums or bone around the teeth are diseased. The patient did not meet criteria for approval. The requested service is denied based on DentaQuest Clinical Criteria for General Anesthesia and IV Sedation and DentaQuest Clinical Criteria for Surgical Extraction. 

The patient's mother is appealing. The summary of the appeal stated that the patient has 4 wisdom teeth that needed to be removed. 

This patient is under the care of a dentist. The dentist has evaluated the patient for impacted wisdom teeth. All the teeth are partial bony impacted. The patient had one of the teeth approved for removal. The anesthesia and the removal of tooth 32 was approved. The request is for extraction of impacted tooth with some bone teeth 1, 16, and 17, intravenous (IV) sedation each 15 minutes and intravenous (IV) sedation each 15 minutes, which is under review. 

There is no evidence these three teeth (1, 16, and 17) would not erupt normally or any symptoms provided in documentation that would necessitate the extraction(s) at this time. As such, the denial is upheld. 

"While symptomatic or diseased impacted wisdom teeth should be recommended for removal, current evidence neither refutes nor confirms the practice of prophylactic removal of asymptomatic, disease-free wisdom teeth" (2). 

"Insufficient evidence is available to determine whether asymptomatic disease-free impacted wisdom teeth should be removed or retained. Although retention of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting adjacent second molars in the long term, the evidence is very low certainty" (3). 

"Removal of third molars, known as wisdom teeth, is one of the most common dental surgical procedures in the United States, representing 95% of all extractions among persons with insurance aged 16 to 21 years. It has been estimated that 10 million wisdom teeth are removed from 5 million individuals in the United States each year, at a cost of more than $3 billion. Dentists recommend early prophylactic removal of asymptomatic third molars to prevent risk of future pathology and to minimize operative and postoperative risks. However, most third molars will erupt without symptoms" (1).     
                                                    
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 extraction of impacted tooth with some bone teeth 1, 16, and 17, intravenous (IV) sedation each 15 minutes and IV sedation each 15 minutes is not substantiated.