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201910-122255

2019

Fidelis Care New York

Medicaid

Dental Problems

Dental/ Orthodontic Procedure

Medical necessity

Upheld

Case Summary

Diagnosis: Decay and missing teeth
Treatment: D2752 - White glass with gold crown, Tooth #29
D3320 - Nerve treatment on bicuspid tooth, Tooth #29

Summary:
The patient is a female requesting benefits for a crown and root canal procedure on tooth #29.

While the patient definitely needs to hold onto this tooth to help chew properly, x-rays submitted do not show much tooth structure missing on tooth #29. An amalgam or composite restoration will be adequate to restore this tooth. There was no periapical x-ray submitted of tooth #29 showing the apex. If there was an infection in the tooth, a periapical x-ray, of the whole length of the tooth, would show this. Since this x-ray was not taken (or submitted), there is no infection seen, and therefore no need for the root canal procedure. A photo showing the full extent of the missing tooth structure might help in diagnosing the need for a crown, but none was submitted.

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