Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wisdom Tooth Impaction

Treatment: D9243 Intravenous Sedation each 15 minutes - 2 units, D7311 Dental Surgery to shape teeth, upper right quadrant, upper left quadrant, lower right quadrant, D0367 Computed Tomography (CT) scan, D7230 Extraction of impacted teeth #'s 1, 16 and 32, D9219 Evaluation general anesthesia

The insurer denied coverage for D9243 Intravenous Sedation each 15 minutes - 2 units, D7311 Dental Surgery to shape teeth, upper right quadrant, upper left quadrant, lower right quadrant, D0367 Computed Tomography (CT) scan, D7230 Extraction of impacted teeth #'s 1, 16 and 32, D9219 Evaluation general anesthesia

The denial is upheld 

This patient is under the care of a dentist for the evaluation and removal of four wisdom teeth. The teeth are impacted. The records mention the use of intravenous (IV) sedation. This case was denied due to a lack of clinical information. The lower wisdom teeth and the general anesthesia for 30 minutes was approved. The upper teeth and additional anesthesia were denied.

The records provided do not support this request for D9243 Intravenous Sedation each 15 minutes - 2 units, D7311 Dental Surgery to shape teeth, upper right quadrant, upper left quadrant, lower right quadrant, D0367 Computed Tomography (CT) scan, D7230 Extraction of impacted teeth #'s 1, 16 and 32, D9219 Evaluation general anesthesia. There is no evidence to support this request in the records provided. There is no indication the surgery is extensive, reported complications or with dental phobia. Therefore, the D9243 Intravenous Sedation each 15 minutes - 2 units, D7311 Dental Surgery to shape teeth, upper right quadrant, upper left quadrant, lower right quadrant, D0367 CT scan, D7230 Extraction of impacted teeth #'s 1, 16 and 32, D9219 Evaluation general anesthesia is not considered medically necessary for this patient.

"Most of the time third molars can be removed with little or no pain. Usually they can be extracted at the oral and maxillofacial surgery office. Patients are given either local anesthesia, intravenous sedation or general anesthesia. Your surgeon will recommend the anesthetic option that is right for you" (1).

"Considering the drugs now available, the ability to control pain without the loss of consciousness, and the retaining of protective reflexes, would depend entirely upon the degree of noxious stimuli produced. In other words, the effectiveness of sedalgesia is in indirect proportion to the degree of painful stimuli. This dictates that to be effective in cases when the degree of painful stimuli is moderate to severe, regional or local analgesia must be utilized to block pain perception. The sedalgesic medication should reduce reaction to any real or emotional stimuli or stress and may elevate the pain threshold to a degree dependent upon the drugs used" (2).                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D9243 Intravenous Sedation each 15 minutes - 2 units, D7311 Dental Surgery to shape teeth, upper right quadrant, upper left quadrant, lower right quadrant, D0367 CT scan, D7230 Extraction of impacted teeth #'s 1, 16 and 32, D9219 Evaluation general anesthesia is not substantiated.