Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class 1 Arch Deficiency and Severe Impaction of Mandibular 2nds and 3rd Molars with Active Resorption visible.
 
Treatment: Dental Imaging and Dental Procedure 

The insurer denied CT scan, extraction of impacted tooth covered by bone, Tooth 32, 17, 16 & 1, general anesthesia - each 15 minutes and biopsy of bone or tooth, Tooth 32. The denial was modified. 

The patient is an adolescent male who was evaluated and noted to have impacted teeth #'s 1, 16, 17, 18, 31, and 32.  The dentist recommended the removal of all six impacted teeth.  The patient was referred to the Oral and Maxillofacial surgeon (OMS) for consultation. The recommendation was to remove all six impacted under sedation.  There is mention of pain, deep periodontal pocketing, and erosion of non-impacted teeth.  
The wisdom teeth and lower second molars are deeply impacted.  There are significant periodontal areas of bone loss on the distal of both first molars. While the patient is young, these teeth should be removed to allow for bone deposition.  The standard of care is to extract these teeth.  There is no evidence of any lesion that requires biopsy. The removal of these teeth is quite difficult and anesthesia is recommended due to degree of difficulty, proximity of the nerve, and proximity to the lower inferior border of the jaw.  However, there is no evidence of any lesion that requires biopsy.  

Per Dodson, T. B., & Susarla, S. M. (2014), "While there has been disagreement about the removal of asymptomatic, disease-free wisdom teeth, there has been no controversy about the need to remove symptomatic teeth and those showing pathological changes such as infection, non-restorable caries, cysts, tumors, or destruction of adjacent teeth and bone.  Most commonly, wisdom teeth are removed because they are impacted against bone or soft tissue, preventing them from fully erupting." Per Cunha-Cruz, J. et al. (2014), "General dentists recommended removal of 1683 third molars from 469 (59%) participants, mainly to prevent future problems (79%) or because a third molar had an unfavorable orientation or was unlikely to erupt (57%).  Dentists recommended retention and monitoring of 1244 third molars from 366 (46%) participants, because it was too early to decide (73%), eruption path was favorable (39%), or space for eruption was sufficient (26%). When dentists recommended removal, 55% of participants adhered to this recommendation during follow-up, and the main reason was availability of insurance (88%)."

Per Dovigi EA. et al. (2016), "The authors reported reactive lesions were the most prevalent disease type found in the sample (74.9%).  Malignant diagnoses comprised 1.97% of all biopsies.  The 3 most prevalent diagnoses in this study included benign keratosis, chronic apical periodontitis, and radicular cyst.  Different anatomic sites, patient age groups, and sexes show different distributions of disease."
                                                         
Based on the above, the medical necessity for requested dental services: CT scan, extraction of impacted tooth covered by bone, Tooth #'s 32, 17, 16 & 1, general anesthesia - each 15 minutes and biopsy of bone or tooth, Tooth 32 is modified. 

CT scan, extraction of impacted tooth covered by bone, Tooth #'s 32, 17, 16 & 1, and general anesthesia each 15 minutes are medically necessary. The insurer did not act reasonably, or with sound medical judgment, or in the best interest of the patient.

Biopsy of bone or tooth, Tooth 32 is not medically necessary. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest in their denial of this procedure. 

Approve CT scan, extraction of impacted tooth covered by bone, Tooth #'s 32, 17, 16 & 1, and general anesthesia each 15 minutes. Biopsy of bone or tooth, Tooth 32.