Diagnosis: Dental issues
Treatment: Apicoectomy on tooth #21, retrograde filling on teeth #s 21 and 22, and anesthesia

The proposed apicoectomy on tooth #21 and retrograde filling on teeth #s 21 and 22 are medically necessary; however, the anesthesia services are not.

The case is an appeal request for surgical endodontic therapy (apicoectomy) and retrograde filling of the apex, in two teeth - #'s21 and 22, for an adult dental patient. The teeth have had previous conventional endodontic therapy, and are restored with crowns. There is radiographic evidence of peri-apical pathology / peri-apical periodontal bone resorption indicative of chronic inflammation, leakage or tissue necrosis requiring treatment. The requested surgical treatment is reasonable and indicated. In this case, the two teeth have shown prior therapy, are not amenable to conventional retreatment endodontic therapy, and are restored with crowns. The requested treatment meets and substantiates standard of care, and approval is recommended.

However, there is no material submitted to substantiate any medical necessity for requested IV anesthesia services (ie, anxiety, medical management issues, complex surgery), and so these services are denied.