Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental restoration with open margins and recurrent staining

Treatment: D2644: Onlay -porcelain/ceramic - four or more surfaces on Tooth # 31

The insurer denied coverage for D2644: Onlay -porcelain/ceramic - four or more surfaces on Tooth # 31. 

The denial is overturned. 

This is a female patient with dental problems. It is clear from the submitted radiographs and photographs that this patient's tooth has a restoration in place with open margins, and recurrent staining which most likely is dental decay. It appears this tooth needs a new restoration and due to the size of the restoration located in the tooth currently, the four surface onlay is a reasonable and conservative restoration.  

According to Vetromilla et al. (2020), "From 11,263 studies identified, 43 studies fulfilled the eligibility criteria and were included in the final review. Only 13 studies were randomized controlled trials and were classified as low risk of bias. Gold (annual failure rate of 0.29%) and metal ceramic (annual failure rate of 0.52%) crowns performed better for indirect restorations and direct resin composite performed better for direct restorations (annual failure rate of 2.19%). The most substantial comparisons were between feldspathic and glass ceramics, followed by direct resin composite and amalgam; there were no statistically significant differences between these interventions.  Results of the pairwise meta-analysis showed mainly glass ionomer as significantly more prone to failure than amalgam and direct composite resin."

Per Laske et al. (2019), "To improve patient dental care, it is necessary to identify possible risk factors for the failing of restorations...his study demonstrated that a wide variation of risk factors on the practice, patient, and tooth levels influences the survival of class II restorations. To provide personalized dental care, it is important to identify and record potential risk factors. Therefore, we recommend further clinical studies to include these patient risk factors in data collection and analysis."

Finally, Javidi et al. (2015) states, "Failed restorations should be repaired where clinically possible, as they are quick and associated with less patient anxiety. Future research should focus on providing high quality prospective data evaluating the longevity of repaired vs replaced restorations."            

In this case, onlay porcelain/ceramic four or more surfaces on Tooth # 31 is considered medically necessary for this patient. As noted above, the tooth in question is in need of removal of the current restoration due to recurrent decay at the margins and open margins. The literature review and dental expertise support that the proposed treatment plan for a four surface onlay is both conservative and reasonable and follows the standard of care and is medically necessary.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.
                                           
The carrier's denial of coverage for D2644: Onlay -porcelain/ceramic - four or more surfaces on Tooth # 31 should be overturned. The medical necessity is substantiated.