Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Impacted Wisdom Teeth.

Treatment: Extraction of impacted tooth covered by bone for tooth #16, general anesthetic - first 15 minutes, general anesthesia - each 15 minutes, and Computed Tomography (CT) scan.

The insurer denied coverage for extraction of impacted tooth covered by bone for tooth #16, general anesthetic - first 15 minutes, general anesthesia - each 15 minutes, and CT scan.

The denial is overturned.

 
The patient was being evaluated for her wisdom teeth removal. All four wisdom teeth are completely impacted. One is distally positioned and asymptomatic and the other three are in reasonably normal position and have pericoronitis associated with them. The plan approved the surgical request for 16,17,32, but denied the cone-beam computed tomography (CBCT).

The teeth 16,17, 32 were ultimately approved. The use of general anesthesia is vital to the treatment of such complex cases. The amount of time is dependent on many factors to include patient physiology, medical, and psychiatric history, and degree of difficulty of the surgery. To arbitrarily say all teeth, take a specific amount of time is unrealistic. One should never rush surgery or an anesthetic as this can cause untoward outcomes. The CBCT also should have been approved, as there is mention of roots close to the inferior alveolar nerve (IAN) and this allows the surgeon to properly treatment plan the case. This decision follows the standard of care.      

The records support that 16 was symptomatic with pericoronitis. The tooth will never come into a functional position due to current position and amount of space that is available. Further, the anesthesia is very important for these complex surgeries as well as medical and psychiatric histories. Finally, as noted above the CBCT is used to aid in the treatment planning portion of this patient's care. The records show that the IAN is close to both roots other lower wisdom teeth. The CBCT will aid in determining how to treat this patient.

"Panoramic imaging has been the first-choice radiographic method when assessing impacted third molars and associated disease.1 Pathology such as external root resorption (ERR) and marginal bone loss may, however, be difficult to observe due to over projection of anatomical structures and neighboring teeth, particularly in the maxillary third molar region. A previous study has shown that panoramic imaging was not able to predict ERR when compared to a three-dimensional radiographic method, CBCT, while panoramic imaging was to some extent able to predict marginal bone loss.2 Nonetheless, CBCT exposes the patient to a higher radiation dose than panoramic imaging,3,4 and for that reason it is important only to perform a CBCT examination on evidence-based indications." (Hermann, et al., 2019)

"Impacted wisdom teeth may be associated with pathological changes, such as pericoronitis, root resorption, gum and alveolar bone disease." (Ghaeminia, H., et al. 2020)

"The scientific evidence therefore suggests that erupted and impacted molars should be removed in the presence of painful symptoms associated to infection, dental caries or altered periodontal health of the adjacent teeth. Likewise, removal is considered to be indicated when the molar may pose problems for planned prosthodontic, orthodontic or surgical treatments." (Penarrocha-Diago, M. et al. 2021)                                                      

Based on the above, the insurer's denial must be overturned. 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 extraction of impacted tooth covered by bone for tooth #16, general anesthetic - first 15 minutes, general anesthesia - each 15 minutes, and CT scan services is substantiated.