Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bone loss
Treatment: D2750 White Glass with High Gold Content Crown Tooth 10, D4341 Deep Gum and Root Cleaning, Lower on All Four Quadrants
The insurer denied the D2750 White Glass with High Gold Content Crown Tooth 10, D4341 Deep Gum and Root Cleaning, Lower on All Four Quadrants
The denial is upheld

The patient is a female whose dentist is requesting treatment of a crown for tooth #10 and four quadrants of deep cleaning (scaling and root planning.)  Per the narrative submitted by the patient's dentist, the patient had hot and cold sensitivity, pain and bleeding from tooth #10 and there was a deep existing composite resin filling in place.  The dentist reported the nerve of the tooth because infection and inflamed at the apex and root canal treatment was necessary and subsequently performed.  The dentist also stated "Patient has trauma to the tooth" but did not explain how, when or the extent of the trauma.  The dentist further stated, "the tooth is grossly discolored and traumatized, is very brittle, and may break down further without PFM" (crown) "tooth is now a shade of blue and grey."

The patient's dentist also submitted a periapical x-ray of tooth #10 (pre- and post-operative), periodontal charting and a panoramic x-ray.  Review of pre-operative PA X-ray provided reveals a small composite restoration on tooth #10.  It also shows localized bone loss distal of #10.  Periodontal charting reveals a probing depth of 4 mm (millimeters) at the distal of tooth #10.  The x-ray of the pre-operative status of the tooth and after the tooth had root canal treatment do not show decay or significant breakdown such that the tooth is compromised or the crown portion of the tooth is weakened at risk for fracture.  There was no mention of the occlusal relationship of #10 with any other tooth. The panoramic x-ray provided is not diagnostic for generalized bone loss in any of the four quadrants.  The only apparent bone loss is at the distal of tooth #10. The requested services were previously denied because tooth #10 "does not seem to have significant breakdown due to decay or trauma" and "there is no evidence of significant bone loss" to support the need for scaling and root planing.

No, the proposed treatment is not medically necessary.
There was no description by the patient's dentist to show pathologic destruction to more than 50% of the crown of tooth #10 (to include incisal edge and incisal line angle or 4 or more surfaces.)  Due to lack of evidence of decay or trauma, and lack of clinical description of breakdown of the crown of the tooth, a porcelain fused to metal (PFM) crown for tooth #10 is not medically necessary at this time.

Scaling and root planing is indicated for acute periodontal disease which is diagnosed based on clinical and radiographic assessment.  There was no narrative about oral hygiene status or clinical description of the quality of gum tissue, nor presence of calculus, bleeding index, mobility, furcation status or diagnosis of bone loss.  The patient's dentist did not provide a diagnosis of periodontal disease for this patient.  Further, the provided x-rays did not show significant bone loss (2.5+ (plus) mm (millimeters) from the cemento-enamel junction) or radiographic evidence of subgingival calculus in any of the four quadrants.  While the submitted periodontal charting shows 2-7 mm (millimeters) probing depths for this patient, there is no evidence of radiographic calculus or bone loss.  Therefore, four quadrants of scaling and root planing is not medically necessary for this patient.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The health plan used the provided X-rays, periodontal charting and clinical description of tooth #10 to determine if the requested services of D2750 and D4341 x 4 quadrants were medically necessary for this patient.