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202009-131535

2020

Principal Life Insurance Company

PPO

Dental Problems

Dental/ Orthodontic Procedure

Medical necessity

Upheld

Case Summary

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Dental Problems
Treatment: Periodontal Scaling and Root-Planning, per Quadrant [D4341/UR and D4341/LR]
The insurer denied Periodontal Scaling and Root-Planning, per Quadrant [D4341/UR and D4341/LR]. The health plan's determination is upheld.

The patient is a female who presents for evaluation and treatment of her upper right and lower right dentition with scaling and root planning (D4341). Provided for review are previous letters of appeal and denial, a letter from the provider from an unknown date, full mouth radiographic images from 7/20/20, two pages of American Dental Association (ADA) claim forms, and periodontal indices. In question is the medical necessity of the planned treatment of scaling and root planning 4341 for UL (upper left) and UR (upper right).

The Periodontal Scaling and Root-Planning, per Quadrant [D4341/UR and D4341/LR] is not medically necessary for this patient. Although there are deeper probing depths, this does not equate the to the presence of attachment loss. As periodontal disease requires the presence of attachment loss and as there is no documented clinical attachment loss and as the radiographic appearance shows the bone level at the CEJ (cemento-enamel junction), there is not any evidence provided of attachment loss. Further supporting the absence of attachment loss is the presence of intact lamina dura throughout the upper right and lower right quadrants of the mouth.

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