Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty chewing.
Treatment: D6010 Surgical placement of implant body, D6056 prefabricated abutment, D06059 abutment tooth #30, root canal and crown tooth #31.
The insurer denied the D6010 Surgical placement of implant body, D6056 prefabricated abutment, D06059 abutment tooth #30, root canal and crown tooth #31.
The denial is overturned, in part. 

This is a male who has been denied an implant, abutment and crown in the #30 area as there was no letter from the his physician and dentist that this is the only viable treatment. A root canal and crown for #31 have been denied as this can only be approved if this is a critical abutment for an existing prosthesis. The radiograph shows that the patient has a bridge that extends from #29 to #31.

Yes, in part: The implant, abutment and crown in the #30 area are medically necessary; however, the root canal for #31 is not.

The options in this case to restore function in the #30 area are an implant, partial denture or a bridge. Implants are the best option. A partial denture has been shown to lead to the loss of adjacent teeth and have less chewing efficiency than implants. A bridge is considered radical treatment as adjacent tooth structure must be drastically reduced in this process. The bridge has been regarded as the standard of care for some time in the replacement of single and multiple missing teeth. However, to obtain optimal functional and aesthetic results for full-veneer bridges, a significant reduction in the amount of tooth structure is necessary occasionally predisposing to endodontic, periodontal, and structural complications. The abutment teeth often become carious and have an increased rate of needing a root canal procedure. If one of the abutment teeth are lost a longer span bridge would be required. The implant procedure is more conservative and has a better prognosis. Implants have a high rate of success, do not require procedures on adjacent teeth and are not susceptible to caries. The implant procedure is not complete until it has been restored. The abutment and crown are needed to complete the restoration and are medically necessary. 

To perform successful endodontic treatment, it is first necessary to correctly diagnose the affected tooth or teeth. This diagnosis can often be simple where there is a large carious cavity and there are healthy, restoration-free adjacent teeth, or it can be extremely complex where the symptoms are less defined and there have been multiple endodontic procedures on numerous teeth. Irrespective of the details of the case, the same protocol of examination and testing should be employed in each instance in order to obtain the most precise response and establish an accurate diagnosis. An examination should always be initiated by obtaining the patient's chief complaint. Understanding previous dental history is a critical step when obtaining information related to the chief complaint. It is important to determine whether a patient has had any recent dental treatment in the area where he or she is experiencing discomfort. It is not unusual for patients who have had a scaling and root planning procedure to experience cold sensitivity due to exposure of dentinal tubules following calculus or cementum removal. The placement of new filling restorations or crown/bridge abutment preparations also needs to be identified as part of the dental history. It is inevitable that any form of tooth reduction by caries formation, caries removal or mechanical preparation causes injury to the pulp. The pulp's capacity to repair is dependent on two factors: the extent of the injury and the existing pulpal health. Studies have shown that crown/bridge abutment preparations produce some of the most damaging effects on the pulp. A series of tests should be performed. These include: Palpation, mobility, percussion, bite test, sensitivity to cold and heat, pulp vitality tests, transillumination and periodontal probing. Compilation of the information obtained from the results of all tests enables accurate endodontic diagnosis and formulation of a treatment plan. As a result of this comprehensive testing, the offending tooth should have been identified and a pulpal diagnosis made. 

There is no chief complaint, history or diagnostic tests to support the need for endodontic therapy for tooth #31. There are also no large carious lesions or obvious periapical pathology. The need for a crown is not supported until the vitality of #31 is known.

No, in part: The health plan did not act reasonably, with sound medical judgement and in the best interest of the patient in that part of the services are medically necessary; specifically the implant, abutment and crown in the #30 area are medically necessary.

The reasons for the denial are not in the best interest of the patient. Implants are the standard of care. To require a letter from the patient's physician and dentist is not valid. The root canal was denied because tooth #31 was not an abutment for an existing prosthesis.  Tooth #31 is an abutment for an existing prosthesis.