Diagnosis: Dental Sensitivity.
Treatment: Crowns on teeth #8 and #9.

The insurer is denied coverage for crowns on teeth #8 and #9. The denial is upheld.

This is a patient who consulted a dentist for an evaluation for sensitivity on teeth #8 and #9. Diagnostic images were performed that included periapical radiographs. The doctor recommended full coverage crowns for these teeth due to the sensitivity issue and erosion on the lingual aspects of the teeth.

The objective documentation provided for review is periapical radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting either #8 or #9. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental services as enumerated above; therefore, the requested crowns are deemed not medically necessary.

Uphold the denial of coverage for crowns on teeth #8 and #9 as not medically necessary, as the documentation is insufficient to justify or substantiate the treatment.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The carrier's denial of coverage for Crowns on teeth #8 and #9 is upheld. The medical necessity is not substantiated.