Diagnosis: Periodontal pocketing and calculus

Treatment: Request for periodontal scaling and root planing

The insurer denied the request for periodontal scaling and root planing. The denial was upheld.

This patient presented for evaluation for dental services and periodontal therapy. There were documented periodontal chartings indicating scattered 3-5 mm periodontal pocketing and calculus. The recommended treatment was scaling and root planing in all four maxillary and mandibular quadrants.

Upon review of the periodontal probing and bitewing and periapical radiographs, there is minimal if any loss of alveolar bone height affecting these teeth. The increased pocket depths likely represent pseudopocketing due to superficial calculus accumulation and poor oral hygiene. It is focal and isolated to only a few teeth in these quadrants. The dental treatment notes do not reflect a diagnosis of periodontitis.

Deep cleaning (periodontal scaling and root planing) of the entire mouth (LL, LR, UL, UR) was not medically necessary as the clinical and radiographic documentation does not support or substantiate scaling and root planing services.

Based on the above, the medical necessity for Deep Cleaning (periodontal scaling & root planning is not substantiated. The insurer's denial is upheld.