Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dental Pain.

Treatment D0367 computed tomography (CT) scan, D7240 extraction of impacted tooth covered by bone, tooth 1, 16, and D9223 general anesthesia - each 15 minutes.

The insurer denied coverage for D0367 computed tomography (CT) scan, D7240 extraction of impacted tooth covered by bone, tooth 1, 16, and D9223 general anesthesia - each 15 minutes.

The denial is modified.

This is the case of a female patient who presented to the dentist's office for an evaluation. Dental X-rays were taken. The patient reported intermittent pain and discomfort with wisdom teeth on the lower left. The treating dentist examined the patient and determined that she needed D0367 computed tomography (CT) scan, D7240 extraction of impacted tooth covered by bone, tooth 1, 16, and D9223 general anesthesia - each 15 minutes.

The American Association of Oral and Maxillofacial Surgeons (AAOMS) Parameters of Care state that an impacted third molar, that is so positioned that it will probably not erupt by the middle of the third decade, constitutes pathology with dental and medical consequences. To limit known risks and complications associated with surgery, it is medically appropriate and surgically prudent to remove impacted third molars before the middle of the third decade and prior to complete root development. The patient meets these criteria. The removal of teeth #1 and #16 are medically necessary based on the standard of care. The wisdom teeth are indicated for removal and medically necessary. 

Panoramic radiographs are the most widely used technique for evaluating the morphology of an impacted 3rd molar, as well as the relationship between the tooth and the mandibular nerve canal. Panoramic radiographs simply do not show the buccolingual position of the canal. Many publications reference 9 signs that are used on panoramic radiographs to assess the relationship between the canal and impacted 3rd molars. There is no universal agreement as to which of these 9 signs is the best predictor of exposure of the nerve or a clinical complication. There appears to be general agreement that the absence of positive radiographic signs on the panoramic film is more useful than is the presence of such signs. 

The CT is the best imaging modality for showing the location of the canal in both the superior-inferior and buccolingual dimensions. There is an ongoing debate in the literature about the need for CT scans before 3rd molar removal, even when 1 or more of the signs is noted on the panoramic image. What is suggested is that clinicians use CT scans selectively on those patients whose panoramic images show 1 or more of the classic signs. 

Advanced 3D reconstructions to evaluate impacted 3rd molars provide information beyond that provided by radiographic images. The submitted panorex does not show any of the signs indicated for a CT. A CT image does not reduce patients' risk of experiencing inferior alveolar nerve (IAN) injuries nor does it affect their prognosis. If the provider is concerned about paresthesia, a coronectomy can be performed. The additional anesthesia (D9223) is not medically necessary without the proper documentation. This would include the anesthesia record which documents the anesthesia time utilized. 

Based on the records reviewed, there was sufficient evidence to support that D7240 extraction of impacted tooth covered by bone, tooth #1 and #16 was considered medically necessary treatment for the patient's condition. However, there was not sufficient evidence to support that D0367 CT scan or D9223 general anesthesia - each 15 minutes were medically necessary.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient in denying code D7240 but did act reasonably in denying codes D0367 and D9223.

The insurer's denial of coverage for D0367 computed tomography (CT) scan, D7240 extraction of impacted tooth covered by bone, tooth 1, 16, and D9223 general anesthesia- each 15 minutes is modified. Medical necessity is partially substantiated.