Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dental Plaque/Stains

Treatment: Cleaning of tooth roots (deep cleaning) for the whole mouth and surgery to place metal post in jaw for teeth #'s 18, 19, 20, 30, and 31

The insurer denied coverage for cleaning of tooth roots (deep cleaning) for the whole mouth and surgery to place metal post in jaw for teeth #'s 18, 19, 20, 30, and 31.

The denial is overturned, in part.

Upon review of submitted documentation, which includes copies of undated full mouth series radiographs, dental/periodontal probing depths, treatment planning, undated letter, and insurer correspondence, it appears that this patient presented to the dentist for care, with identification of periodontal disease in all four quadrants. Recommended treatment was four quadrants of scaling and root planning given multiple areas of 5 or more mm (millimeters) pocketing. In addition, the dentist recommended endosteal implants at edentulous sites # (number) 18, 19, 20, 30, and 31.

In this case, as regards documentation of the periodontal status, in particular the periodontal charting and radiographs, it is evident that there is a level of periodontal disease where there is root surface exposure and alveolar bone loss. All four quadrants exhibit multiple areas of 5 mm pocket depths and radiographic calculus is noted in all quadrants. Appropriate treatment would be the recommended scaling and root planning to address any ongoing periodontal issues. This would be standard of care treatment given the alveolar bone loss and level of periodontal disease as documented on the clinical and radiographic findings. As such, these services are considered dentally necessary.

Based on the submitted documentation, it is evident on radiographs that several teeth may not be maintainable, and the patient exhibits oligodontia in the mandible. At issue is restorative/prosthodontic options for this patient. In this case, implants and implant retained crowns would be an acceptable treatment plan, as recommended by the dentist. However, implant and restorative services are not the only treatment options. In this case, fabrication of a mandibular removable denture is an acceptable and appropriate option and a standard of care in general dental practice.

Modify denial and approve coverage for cleaning of tooth roots (deep cleaning) for the whole mouth as medically necessary, as the clinical and radiographic documentation support and substantiate this recommended treatment. Uphold denial of surgery to place metal post in jaw for teeth #'s 18, 19, 20, 30, and 31, as alternative appropriate treatment for this patient would be a removable partial denture. 

The health care plan did not act reasonably, with sound medical judgement, or in the best interest of the patient as regards to scaling and root planning.

The health care plan acted reasonably, with sound medical judgement, and in the best interest of the patient as regards to implant services.


The insurer's denial of coverage for the cleaning of tooth roots (deep cleaning) for the whole mouth and surgery to place metal post in jaw for teeth #'s 18, 19, 20, 30, and 31 is overturned, in part. Medical necessity is partially substantiated, as described above.