Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Teeth Pain

Treatment: D7240 extraction of impacted tooth covered by bone for teeth 1, 16, 17, and 32; D9222, general anesthetic - first 15 minutes; D9223 general anesthesia - each 15 minutes; D9230, relaxation gas

The insurer denied coverage for D7240 extraction of impacted tooth covered by bone for teeth 1, 16, 17, and 32; D9222, general anesthetic - first 15 minutes; D9223 general anesthesia - each 15 minutes; D9230, relaxation gas

The denial is modified

This is an adolescent patient who has undergone orthodontia. The patient has some pain from the movement of the wisdom teeth. The wisdom teeth are all complete bony impactions. The patient has seen an Oral and Maxillofacial Surgery (OMS) and been planned for the removal of the wisdom teeth with intravenous (IV) sedation.

D7240 is surgical extraction of complete bony impaction and medically necessary in this case. The patient has undergone prior orthodontia and feels the teeth moving. This movement which is eliciting pain and pressure could shift teeth as the wisdom teeth move. The patient is symptomatic, and the removal of these teeth is difficult, and this is why the anesthesia is recommended. This should be considered medically necessary as the patient can develop an orthodontia relapse. 

However, D9230 is part of the D9222 and D9223. In this case, the D9222 and D9223 are medically necessary and used for analgesia and complex cases. Further the mention of pain and swelling should be considered pericoronitis. This can develop further into an infection. This information is all provided in the records.

Gadhia, A., and Pepper, T. (2023), "A dental extraction can be offered to patients for a multitude of reasons. While the emphasis is always placed on retaining as much of the dentition as possible, there are cases where this is no longer feasible or in the patient's best interest. Impacted teeth are those that cannot erupt due to a physical barrier. Teeth that are impacted against other teeth or within the jaw are often considered for removal. If left impacted within the jaw, impacted teeth follicles have the potential for cystic change. National clinical guidelines often govern the specific indications for mandibular third molar removal. 

Per Ghaeminia, H., et al. (2020), "Prophylactic removal of asymptomatic disease-free impacted wisdom teeth is the surgical removal of wisdom teeth in the absence of symptoms and with no evidence of local disease. Impacted wisdom teeth may be associated with pathological changes, such as pericoronitis, root resorption, gum and alveolar bone disease (periodontitis), caries and the development of cysts and tumors. When surgical removal is performed in older people, the risk of postoperative complications, pain and discomfort is increased. Other reasons to justify prophylactic removal of asymptomatic disease-free impacted third molars have included preventing late lower incisor crowding, preventing damage to adjacent structures such as the second molar or the inferior alveolar nerve, in preparation for orthognathic surgery, in preparation for radiotherapy or during procedures to treat people with trauma to the affected area."

Penarrocha-Diago, M., et al. (2021), "Extraction is indicated in the presence of disease associated to an impacted 3rd molar, whether symptomatic or not. In contrast, extraction is not indicated in the absence of infection or other associated disease conditions." 

Based on the above, the insurer's denial must be modified. 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 D7240 extraction of impacted tooth covered by bone for teeth 1, 16, 17, and 32; D9222, general anesthetic - first 15 minutes; D9223 general anesthesia - each 15 minutes is substantiated, and insurer's denial must be reversed. The medical necessity for D9230, relaxation gas is not substantiated and insurer's denial for D9230 must be upheld.