The patient is a female who presents to the office of her dental provider for evaluation and treatment of teeth #7, 8, 9, 10. Included with records for review are a narrative from the patient's daughter, full mouth radiographic images, American Dental Association (ADA) claim forms, and health plan language. In question is the medical necessity of the planned treatment of porcelain fused to metal abutment tooth for fixed partial denture # 6 and 11(6750) and porcelain fused to metal pontic tooth for teeth #7, 8, 9, 10 (6240).
Previous denials have been on the basis that there is insufficient evidence of restorative need for replacement of the current restoration. Based on the provided documentation there is not decay nor any evidence of failure of the current fixed dental prosthesis (FPD) from 6-11.

The health plan's determination is upheld.

No, the requested health service/treatment of Bridge replacing teeth number 7, 8, 9, 10 and 11 is not medically necessary for this patient. There is no evidence from the provided documentation that there is any decay at the margins or any type of failure of the restoration.
The space under the pontic sites is not an indication for replacing the fixed partial denture. The space under the pontic site from the radiographs shows the bone in close proximity to the pontics themselves. All speaking sounds such as F, V, S are determined by the incisal edges of the teeth and not the space under the pontic. The anterior teeth are involved in cutting food off, and the chewing of the food is done by the posterior teeth. As the fixed partial denture is not failed and not moving, it does not prevent eating nor chewing and its efficacy for speaking and chewing remains unchanged from the time of fixation.
There is no restorative need for replacement of the current restoration.