Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth Fracture
Treatment: Procedure code D2792, porcelain crowns to teeth 18, 19, 30, and 31
The insurer denied coverage for procedure code D2792, porcelain crowns to teeth 18, 19, 30, and 31.
The denial is overturned.

There was no medical or dental history was included. High-quality clinical photographs and radiographs of the teeth in question were reviewed. Teeth #18, 19, 30, and 31 are observed to have fractured tooth structure and amalgam fillings with recurrent decay surrounding them. The procedure in question is porcelain full-coverage crowns on Teeth #18, 19, 30, and 31. The reason for the proposed procedure is that the patient has old, large, cracking silver fillings on these teeth, and the teeth themselves are showing signs of fracture and recurrent decay.

This review considered the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations.

The treatment in question should be approved for the patient because the crowns are medically necessary based on the fractures observed on the submitted clinical documentation as well as the plan language regarding crowns. Practice guidelines from current evidence-based dental research confirms these findings.      

New fillings are not an option for this patient because when the old fillings are removed, there will be insufficient tooth structure remaining to allow proper placement of a filling. Therefore, the teeth in question require full-coverage crowns to protect them from further fracture and restore proper function to the teeth. Crowns on these teeth will help to prevent pain, swelling, and infection for the patient in the future.

"Dentists recommend single-unit crowns for many reasons. A tooth might have a large carious lesion, a fracture, or a large filling, putting the tooth at risk for further breakdown. A tooth might be a source of pain, suggesting a crack, or a tooth might have had endodontic treatment. These situations may prompt a dentist to recommend a crown in order to increase the tooth's longevity and optimize the patient's oral health." (McCracken et al 2016).

"Decisions for when to restore carious lesions should include at least clinical criteria of visual detection of enamel cavitation, visual identification of shadowing of the enamel, and/or radiographic recognition of enlargement of lesions over time. The benefits of restorative therapy include: removing cavitations or defects to eliminate areas that are susceptible to caries; stopping the progression of tooth demineralization; restoring the integrity of tooth structure; preventing the spread of infection into the dental pulp; and preventing the shifting of teeth due to loss of tooth structure." (AAPD 2016).          

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the procedure code D2792, porcelain crowns to teeth 18, 19, 30, and 31 is overturned. Medical Necessity is substantiated.