Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Avulsion of tooth 12, 18, 30, and 31 

Treatment: D2960 (plastic crown on front of tooth only made by dentist for teeth 7, 8, 9, 10, 11 and 12), D6104 (Bone graft at time of implant placement for teeth 18, 30 and 31), D4266 gum surgery for teeth 30 and 31), D6010 (implant placement for teeth 18, 30 and 31), D6057 (custom abutment for teeth 18, 30 and 31) and D6058 (abutment supported porcelain/ceramic crown Tooth 18, 30 and 31). The denial is upheld.

This patient is a male who has been treatment planned for crowns on teeth 7-12 and also removal and replacement of 18, 30, 31 with dental implants and bone grafts with tissue guided regeneration. A doctor's letter states that the patient needs permanent dental implants due to avulsion of tooth 12, 18, 30, and 31. The patient complains of pain and headache. Dentures would not prevent long term bone loss, and long term risk of worsening dentition, bone loss, and pain. An appeal states implants fixture will avoid permanent loss of bone volume. The patient complains of headache, jaw pain, bone depletion, and tooth avulsion. The letter indicates that placing a dental implant and fixed prosthesis is the best option treatment for this patient to restore his mastication for better nutrition. 

According to McCracken, et al. (2016), "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. However, little scientific evidence exists to guide dentists when making certain treatment recommendations..." 

Further, Kolpin, M., et al. (2014) states, "The restoration of endodontically treated teeth involves a difficult decision-making process, especially when it comes to more complex prosthetic rehabilitations. So when is there a need for a single-crown restoration or when might a composite resin restoration also be sufficient? For the assessment of endodontically treated teeth as abutment teeth for prosthetic restorations, there are no clear guidelines beyond single-tooth restorations." 

Lastly, Pratt, et al. (2016) concludes, "Patients may benefit by maintaining their natural dentition by timely placement of crown after RCT, which otherwise may have been extracted and replaced by implant because of any delay in crown placement." 

It appears from a review of the medical records in this case that the plan acted reasonably and responsibly in their judgment. The attached radiographs were reviewed. Tooth 7 has some decay. The records do not support the crowns, periodontal surgery, bone grafts, implants, or abutments. There is no structural reason provided that teeth 7-12 need crowns. The dentition from 7-12 appears intact, except for tooth 7 has some decay based on the records received for this case, it appears this tooth can be restored with a composite resin. The records provided do not support any trauma to the lower molars, and do no support that dental implants are medically necessary. There is no evidence of any bone pathology from the records provided for review. 
                                                    
Based on the above, the medical necessity for D2960 (plastic crown on front of tooth only made by dentist for teeth 7, 8, 9, 10, 11 and 12), D6104 (Bone graft at time of implant placement for teeth 18, 30 and 31), D4266 gum surgery for teeth 30 and 31), D6010 (implant placement for teeth 18, 30 and 31), D6057 (custom abutment for teeth 18, 30 and 31) and D6058 (abutment supported porcelain/ceramic crown Tooth 18, 30 and 31) is not substantiated. The insurer's denial is upheld.