Diagnosis: large carious lesions involving the pulp chambers

Treatment: D3330 (root canal) tooth 15, D2751 crown - porcelain (tooth 15, and 30); and D3348 retreatment of previous root canal therapy-molar (root canal, tooth 30)

The insurer denied coverage for D3330 (root canal) tooth 15, D2751 crown - porcelain (tooth 15, and 30); and D3348 retreatment of previous root canal therapy-molar (root canal, tooth 30). The denial was reversed.

This patient is a male patient who presented to the dentist for evaluation and comprehensive dental treatment. Endodontic therapy (including retreatment of #30) was recommended on multiple teeth including #15 and #30 due to large carious lesions and failing root canal on #30, with subsequent recommended treatment of full coverage crowns to be placed.

The insurer has denied these services stating that the services are not medically necessary as these teeth are not supports for a partial denture or bridge.

Upon review of radiographs, they support the recommended treatment. The teeth have large carious lesions involving the pulp chambers radiographically or periapical pathology on #30, both requiring endodontic therapy as identified by the dentist. All have adequate residual coronal structure for support of crowns and minimal periodontal alveolar bone loss. The standard of care in general dental practice would be endodontic therapy for these teeth which would have an excellent long term prognosis with the recommended treatment. Further, standard of care in dental practice would be full coverage restorations on endodontically treated teeth as recommended.

Reverse denial and approve coverage for coverage for D3330 (root canal) tooth 15, D2751 crown - porcelain (tooth 15 and 30); and D3348 retreatment of previous root canal therapy - molar (root canal tooth 30) as medically necessary as the clinical and radiographic documentation support these services, and these services would be a standard of care in general dental practice. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for D3330 (root canal) tooth 15, D2751 crown - porcelain (tooth 15, and 30); and D3348 retreatment of previous root canal therapy-molar (root canal, tooth 30) is substantiated. The insurer's denial is reversed.