Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion 

Treatment: exposure of an unerupted tooth (opening area to allow tooth to come out) for teeth #'s 6 and 11; medicine to put patient to sleep for procedure (deep sedation/general anesthesia, each subsequent 15-minute increment) for teeth #'s 6, 11, and upper right side of mouth, and placement, device to facilitate eruption (putting on a button to help move the tooth) for tooth #6.

The insurer denied coverage for exposure of an unerupted tooth (opening area to allow tooth to come out) for teeth #'s 6 and 11; medicine to put patient to sleep for procedure (deep sedation/general anesthesia, each subsequent 15-minute increment) for teeth #'s 6, 11, and upper right side of mouth, and placement, device to facilitate eruption (putting on a button to help move the tooth) for tooth #6.

The denial is overturned.

Medical history and dental treatment notes and a panoramic radiograph were reviewed. There is no mention of any congenital syndrome affecting growth and development of the head, neck, teeth, or associated structures. The patient required the stated treatments because the permanent upper right and left canines (Teeth #6 and #11), which are anterior teeth, are observed to be impacted in a mesio-angular orientation, almost horizontally, on the attached documentation. Teeth #6 and #11 will most likely not erupt on their own without orthodontic and/or surgical intervention, and this situation may cause long-term permanent problems with growth and development of the jaws, leading to a severely handicapping malocclusion, if not addressed. 

Per Management of the Developing Dentition and Occlusion in Pediatric Dentistry. (2017), "Guidance of eruption and development of the primary, mixed, and permanent dentitions is an integral component of comprehensive oral health care for all pediatric dental patients. Such guidance should contribute to the development of a permanent dentition that is in a stable, functional, and esthetically acceptable occlusion and normal subsequent dentofacial development. Early diagnosis and successful treatment of developing malocclusions can have both short-term and long-term benefits while achieving the goals of occlusal harmony and function and dentofacial esthetics. Dentists have the responsibility to recognize, diagnose, and manage or refer abnormalities in the developing dentition as dictated by the complexity of the problem and the individual clinician's training, knowledge, and experience."

Per Schubert, M., Proff, P., & Kirschneck, C. (2016), "A successful treatment of cases with multiple impactions poses a major challenge for most orthodontists in clinical practice and requires a meticulous treatment planning, preferably in collaboration with a dental surgeon. Apart from complicating the treatment and its predictability, treatment times usually increase significantly and there is considerable concern that the impacted teeth could show or develop signs of invasive cervical root resorption (ICRR) or ankylosis, leaving the patient in the long term with a distinct hypodontia, if an extraction of these teeth becomes necessary. The Easy-Way-Coil (EWC) system used for traction in this case (Adenta, gilching, Germany) has already been shown to be effective in aligning impacted upper canines."

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 exposure of an unerupted tooth (opening area to allow tooth to come out) for teeth #'s 6 and 11; medicine to put patient to sleep for procedure (deep sedation/general anesthesia, each subsequent 15-minute increment) for teeth #'s 6, 11, and upper right side of mouth, and placement, device to facilitate eruption (putting on a button to help move the tooth) for tooth #6 is overturned. Medical Necessity is substantiated.