202005-128299
2020
Fidelis Care New York
Medicaid
Dental Problems
Dental/ Orthodontic Procedure
Medical necessity
Overturned
Case Summary
Diagnosis: Dental Problem
Treatment: D6240 False Tooth for Bridge, Tooth 9 and Tooth 10, and D6750 White Glass with High Gold Content Cap for Bridge, Tooth 8 and Tooth 11
The insurer is denied coverage for D6240 False Tooth for Bridge, Tooth 9 and Tooth 10, and D6750 White Glass with High Gold Content Cap for Bridge, Tooth 8 and Tooth 11.
The denial is overturned.
This is a patient who presented for a dental evaluation. It was reported that the patient has caries on #10 and a preexisting fixed bridge with other missing teeth. It was stated that #10 was non maintainable and a replacement fixed bridge spanning from teeth #8-#11 was the recommended treatment plan from the dentist.
Upon review of the documentation, in particular the radiographs it is evident that the preexisting bridge was failing and #10 was non maintainable with periapical pathology. To restore function to the right maxillary dentition, in this case since the patient has pre-existing fixed bridge, replacement with a fixed prosthesis spanning #8-11 site is the standard of care dental treatment in general dental practice, as recommended. As the dentition is already restored with a fixed bridge prosthesis the only treatment that would be considered appropriate would be for replacement of the fixed bridge.
Reverse denial and approve coverage for D6240 false tooth for bridge tooth 9 and tooth 10 and D6750 white glass with high gold content cap for bridge tooth 8 and tooth 11 was medically necessary as this would be the standard of care dental treatment in clinical practice.
The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient.
The patient D6240 false tooth for bridge tooth 9 and tooth 10 and D6750 white glass with high gold content cap for bridge tooth 8 and tooth 11 is considered medically necessary for this patient.
Based on the above, the medical necessity for D6240 False Tooth for Bridge, Tooth 9 and Tooth 10, and D6750 White Glass with High Gold Content Cap for Bridge, Tooth 8 and Tooth 11 is substantiated. The insurer's denial is overturned.