Diagnosis: Tooth #6, #7, #8, #9 & #10 restored

Treatment: Crowns - porcelain fused to noble metal for Tooth #6, #7, #8, #9, and #10

The insurer denied Crown - porcelain fused to noble metal for Tooth #6, #7, #8, #9, and #10.
The denial was upheld.


This is a middle aged female who has been denied crowns for tooth #6, #7, #8, #9, and #10 because they can be restored with conventional restorations or be removed.
Her record consists of cryptic notes and radiographs which show that the teeth have been restored multiple times. In addition, there is no documentation that a significant portion of the crowns are missing such that a crown is the only restoration that is possible in this case.

According to Malament, K. A., et al. (2018), "The objectives of a crown are to restore function and esthetics for a treated tooth. Much of the longevity and esthetic success of the crown restoration relies on both maintenance and prevention routines adopted by the patient." They go on to state, "An important factor to consider in the contour of the restoration is the shape of the pulp. If the pulp is unusually wide, this may be a contraindication for crowning. Indications for the machinable lithium disilicate material are inlays, onlays, veneers, partial crowns, telescope primary crowns, and implant superstructures."

The carrier's denial of coverage for D2752- Crown - porcelain fused to noble metal for tooth #'s 6, 7, 8, 9 & 10 is upheld. The medical necessity is not substantiated.