Diagnosis: Dental erosion/perimolysis
Treatment: Preservice request for dental services (codes 21085, D2644, D2740, and D2962)

The insurer denied coverage for preservice request for dental services (codes 21085, D2644, D2740, and D2962). The denial is upheld.

This patient is a female. Based on review of the submitted documentation which includes copies of narrative letters from the patient, relevant portion of the Medical Benefits guidebook, narrative letter, medical record/treatment notes, montage of undated intraoral clinical photos, undated panoramic radiograph, dental treatment records and treatment plan, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding dental rehabilitation of teeth exhibiting evidence of erosion stated to be due to the patients underlying gastroesophageal reflux disease (GERD). The insurer has denied the aforementioned services stating that these dental services are exclusions from the patient's medical plan coverage, and the insurer will only cover certain oral surgical services under the medical coverage with very specific criteria to be met. As these dental services do not meet the criteria they are considered not medically necessary and no benefit is allowed.

Upon review of the objective documentation it is evident that the patient exhibits significant dental erosion/perimolysis. The erosion is ascribed to manifestations of the patients well documented GERD. The patient and doctor are claiming that the dental services recommended should be covered under her medical insurance contract due to the underlying medical condition and they indicate that she meets the insurer's criteria under oral surgical services. The insurer claims that these dental services do not meet their criteria for approval under the medical insurance contract.

The services to be performed are strictly dental and not oral surgical in nature and therefore these services are best covered under any dental insurance coverage the patient may have. The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the preservice request for dental services (codes 21085, D2644, D2740, and D2962) is upheld.