Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental decay
Treatment: Dental treatment: Crown on teeth 30 and 31
The insurer denied coverage for: Dental treatment: Crown on teeth 30 and 31
The denial is: Overturned
The patient is an adult under the care of a dentist for dental treatment. Teeth 30 and 31 have crowns and 31 has a pin present. The radiographs show dental decay on the cervical margins interproximally. This decay is present on both teeth. The requested treatment plan includes the removal of the crowns and treatment of the decay.

Based on the radiographs the patient needs the crowns removed and the teeth treated. This should include replacement of the restoration.      

A crown on teeth 30 and 31 is considered medically necessary for this patient. Teeth 30 and 31 have crowns and 31 has a pin present. The radiographs show dental decay on the cervical margins interproximally. This decay is present on both teeth. These teeth need to be treated and both have recurrent decay under the crown margins that will be required to be treated.

"In early stages of tooth decay (when white or brown spots appear on the teeth) it might be enough just to brush your teeth regularly with fluoride toothpaste and have a fluoride treatment at the dentist's.

If you have a hole in your tooth, known as a cavity, you will be given a filling. Here the dentist will use a drill to remove decayed material, and then fill the cavity with synthetic resins (composite resins), amalgam, ceramic material or a precious metal. If the tooth damage is more severe, a partial or full crown may be needed for the tooth. If nerves are also affected, root canal treatment is usually recommended. Sometimes the tooth may need to be pulled (extracted). It can then be replaced by a bridge or fixed dentures supported by an implant.

Besides the conventional ways of treating tooth decay, there are a number of newer procedures, some of which no longer use a drill. These include a technique called "caries infiltration" to treat tooth decay in its early stages, which involves using plastic to harden the tooth." (Institute for Quality and Efficiency in Health Care, 2020)

"Recommendations for crowns may be influenced by factors unrelated to tooth and patient variables. A concern for tooth fracture-whether from endodontic treatment, fractured teeth, or large restorations-prompted many clinicians to recommend crowns." (McCracken et al., 2016) 

"The results of this study reveal the prescribing habits of dentists in relation to provision of initial and replacement crowns. The vast majority of patients had only one crown provided per course of treatment, which is probably a reflection of funding schemes and changing patterns of oral health. This sample reported fewer replacement crowns than previous studies. In keeping with existing literature, crowns were more frequently replaced when the treating dentist had not placed the initial crown. However, against this, more replacements were provided for more long-standing patients (5+ years attendance) compared to those with shorter attendance history (<5 years). In an area where high quality evidence is lacking, further consensus on the need for placement and replacement crowns is needed. Such information would assist dentists to provide high-quality care and commissioners in developing an evidence-based service." (Lynch et al., 2018)                                                         

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Crown on teeth 30 and 31 is substantiated.