Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Tooth pain.
Treatment: Periodontal scaling and root planing of ALL quadrants; and root canals and crowns on teeth #3 and #18.

The insurer denied the Periodontal scaling and root planing of ALL quadrants; and root canals and crowns on teeth #3 and #18. The denial is overturned, in part. 

The patient is a male requesting dental benefit coverage for scaling/root planing (D4341)--all four quadrants of the mouth; tooth #3--endodontic therapy (D3330)/post and core (D2954)/crown (D2750); and tooth #18--endodontic therapy (D3330)/post and core (D2954)/crown (D2750).

The patient exam and x-rays indicates substantial loss of coronal aspect --tooth #3. The patient complained of pain from this tooth and that there were lacerations of the cheek from the broken edges of tooth #3. The patient's x-rays are consistent with the complaints and findings as it relates to tooth#3.  The patient also complained of pain from tooth #18.  

Yes, in part; the proposed treatment is medically necessary, in part.  Specifically, the proposed treatment as it related to tooth #3 is medically necessary.  However, the rest of the proposed treatment is not medically necessary; specifically, the periodontal scaling and root planing of all quadrants is not medically necessary, and neither is the root canal and crown on tooth #18.

As it relates to tooth #3 - as evidenced in the clinical summary and the x-ray, there is significant coronal structure (approximately 40 percent of the tooth) that has fractured off with a depth that approximates the pulpal nerve chamber. At this point, the patient would experience extreme sensitivity to hot and cold and severe pain. Endodontic therapy (root canal) D3330 would be indicated to repair and seal the nerve canal. Post and core (D2954)/crown (D2750) would be indicated, as this is the next step needed to protect and restore function of the tooth.

As it relates to scaling/root planing (D4341) - there is no evidence on the x-rays or in clinical summary that supports the need for this procedure.  Scaling/root planing is indicated when there is significant plaque and calculus deposit, bone loss, inflammation of the gingiva and or periodontium.

As it relates to tooth #18 - there is no evidence from the x-rays, or mention in clinical summary, as to the physical condition of tooth #18 that would warrant endodontic therapy(D3330)/post and core(D2954)/crown (D2750).

Yes, in part; the health plan acted reasonably, with sound medical judgment and in the best interest of the patient, in part. Specifically, the proposed treatment as it related to tooth #3 is medically necessary.  However, the rest of the proposed treatment is not medically necessary; specifically, the periodontal scaling and root planing of all quadrants is not medically necessary, and neither is the root canal and crown on tooth #18.

As it relates to tooth #3 - the health plan did not act in the best interest of the patient because it is evident from the x-ray that there is a substantial fracture with near exposure of the nerve canal that would cause the patient to have severe pain and discomfort , especially when eating and drinking.

However, as it relates to tooth #18 (endodontic therapy/post and core/crown) and request for scaling/root planing for all four quadrants, the health plan acted in the best interest of the patient and with sound judgement because there was no evidence on the x-rays or in the clinical summary that would necessitate both of these procedures that are considered invasive if there is no clinical pathology present.