Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental disease

Treatment: D6057 custom abutment, tooth 19, D6058 abutment supported porcelain/ceramic crown, tooth 31, D6057 custom abutment, tooth 31, and D6058 abutment supported porcelain/ceramic crown, tooth 19

The insurer denied coverage for D6057 custom abutment, tooth 19, D6058 abutment supported porcelain/ceramic crown, tooth 31, D6057 custom abutment, tooth 31, and D6058 abutment supported porcelain/ceramic crown, tooth 19

The denial is overturned
 

This patient is an adult who has consulted many dentists and specialists. The patient has undergone extraction of teeth 19 due to vertical root fracture and 31 due to dental infection. Tooth 2 is over erupting. The dentist has placed implants in 19 and 31 sites. There is also mention that 18 is shifting and the patient is having difficulty with mastication, which is causing weight loss. The request is for D6057 custom abutment, tooth 19, D6058 abutment supported porcelain/ceramic crown, tooth 31, D6057 custom abutment, tooth 31, and D6058 abutment supported porcelain/ceramic crown, tooth 19, which is under review.

The patient has undergone extraction of teeth 19 due to vertical root fracture and 31 due to dental infection. The dentist has placed implants in 19 and 31 sites. The restoration of both implants will increase function and prevent tooth migration. Therefore, the D6057 custom abutment, tooth 19, D6058 abutment supported porcelain/ceramic crown, tooth 31, D6057 custom abutment, tooth 31, and D6058 abutment supported porcelain/ceramic crown, tooth 19 are considered medically necessary for this patient.

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. Most dentists would agree, for example, that a large restoration might be a reason to recommend a crown for a particular tooth. The question then becomes, "Exactly how 'large' does a restoration have to be in order to justify recommending a crown for the tooth?" Some dentists might repair a particular restoration, others may replace it, and still others may recommend placing an inlay or a single-unit crown."

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. Regarding single-tooth restoration, there are high-level requirements for the restorative components and the application of all necessary treatment steps to achieve the final restoration. 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 root canal therapy (RCT), which otherwise may have been extracted and replaced by implant because of any delay in crown placement."

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D6057 custom abutment, tooth 19, D6058 abutment supported porcelain/ceramic crown, tooth 31, D6057 custom abutment, tooth 31, and D6058 abutment supported porcelain/ceramic crown, tooth 19 is substantiated.