Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Impacted wisdom teeth.
Treatment:  Extraction of impacted tooth with some bone, tooth 17 & tooth 32 (D7230) and extraction of impacted tooth covered by bone, tooth 1 & tooth 16 (D7240).

The insurer denied the extraction of impacted tooth with some bone, tooth 17 & tooth 32 (D7230) and extraction of impacted tooth covered by bone, tooth 1 & tooth 16 (D7240).  The denial is upheld. 

The patient is a female.  She has been denied removal of her impacted wisdom teeth because there is no documentation of pain, pathology or that the teeth will not erupt on their own.

No, the proposed treatment (extraction of impacted tooth with some bone, tooth 17 & tooth 32 [D7230]; extraction of impacted tooth covered by bone, tooth 1 & tooth 16 [D7240]) is not medically necessary.

Per the American Association of Oral and Maxillofacial Surgeons (AAOMS) guidelines, I. Indications for Therapy for Third Molars, B. Partially erupted third molar tooth: a "partially erupted tooth" that is so positioned that only a portion of the clinical crown is visible:  1) Pain, 2) Pericoronitis, 3) Carious tooth, 4) Facilitation of the management of or limitation of progression of periodontal disease, 5) Non-treatable pulpal or periapical lesion, 6) Acute and/or chronic infection (cellulitis, abscess), 7) Ectopic position, 8) Abnormalities of tooth size or shape precluding normal function, 9) Facilitation of prosthetic rehabilitation, 10) Facilitation of orthodontic tooth movement and promotion of dental stability, 11) Tooth impeding the normal eruption of an adjacent tooth, 12) Tooth in the line of fracture, 13) Tooth involved in tumor resection, 14) Pathology associated with tooth (cysts, neoplasms), 15) Preventive or prophylactic removal, when indicated, for patients with medical or surgical conditions or treatments (organ transplants, alloplastic implants, bisphosphonate therapy, chemotherapy, radiation therapy), 16) Tooth interfering with orthognathic and/or reconstructive jaw surgery, 17) Clinical findings of fractured tooth or teeth, 18) Internal or external resorption of tooth or adjacent teeth, 19) Impacted tooth (as defined previously), 20) Anatomical position causing potential damage to adjacent teeth, or 21) Patient's informed refusal of nonsurgical treatment options.

C. Unerupted/impacted third molar tooth: an "unerupted/impacted tooth" that has not penetrated through bone and/or soft tissue and entered the oral cavity.  Consideration should be given to removal of an unerupted /impacted third molar by the third decade when there is a high probability of disease or pathology and that the tooth will not erupt and when risks associated with early removal are less than anticipated risks of later removal (increased morbidity):  1) Pain, 2) Pathology associated with tooth follicle (cysts, tumors), 3) Abnormalities of tooth size or shape precluding normal function, 4) Facilitation of the management of or limitation of progression of periodontal disease, 5) Resorption of adjacent tooth, 6) Facilitation of orthodontic tooth movement and promotion of stability of the dental occlusion, 7) Facilitation of prosthetic rehabilitation, 8) Tooth impeding the normal eruption of an adjacent tooth, 9) Tooth in the line of fracture, 10) Tooth involved in tumor resection, 11) Tooth interfering with orthognathic and/or reconstructive jaw surgery, 12) Preventive or prophylactic tooth removal, when indicated, for patients with medical or surgical conditions or treatments (organ transplants, alloplastic implants, bisphosphonate therapy, chemotherapy, radiation therapy), 13) Clinical findings of fractured tooth or teeth, 14) Pathology associated with the impacted tooth (odontogenic cysts, neoplasms), 15) Internal or external resorption of tooth or adjacent teeth, 16) Need for donor transplant or stem cell harvest, 17) Facilitate harvesting of autologous graft, 18) Impacted tooth (as defined previously), 19) Anatomical position causing potential damage to adjacent teeth, or 20) Patient's informed refusal of nonsurgical treatment options.

IV. Indicated Therapeutic Parameters for Third Molar Removal.  The presurgical assessment includes, at a minimum, a history and both a clinical and an imaging evaluation.  

The records do not document any of the reasons to indicate that removal of the wisdom teeth is necessary.  There is no history and no clinical evaluation included in the records for review.