Diagnosis: Dental Disorder
Treatment: Dental/Orthodontic Procedure

The insurer denied the build up on tooth #15. The denial is upheld.

The patient presented for evaluation and treatment of tooth number (#) 15. Provided for review are previous letters of appeal and denial, a narrative from office staff explaining radiographic opening under the failed restoration #15, radiographic images, one page of American Dental Association (ADA) claim forms, and health plan language.
Previous denials have been on the basis that the tooth has adequate remaining tooth structure to support the crown prosthesis. There are no clinical notes provided describing the resulting amount of tooth structure after removal of decay. There is a narrative provided by an office staff but no official notation from the patient chart signed by the doctor. At issue question is the medical necessity of the planned treatment of buildup (2950) for tooth #15.

The build up on tooth #15 is not medically necessary. The documentation provided does not support the need for the buildup procedure. The radiographic images provided show that there is adequate tooth structure to support the crown prosthesis and there is not the need for a buildup.