202104-136969
2021
Fidelis Care New York
Medicaid
Dental Problems
Dental/ Orthodontic Procedure
Medical necessity
Upheld
Case Summary
Diagnosis: Dental issue
Treatment: White Glass with Gold Crown, Tooth 3
The insurer denied a White Glass with Gold Crown, Tooth 3. The health plan's determination is upheld
The patient is a male who presents for evaluation and treatment of tooth #3. Provided for review are previous letters of appeal and denial, full mouth radiographic images, multiple pages of American Dental Association (ADA) claim forms, and a narrative from the treating provider.
In question is the medical necessity of white glass with gold crown, tooth 3.
Based on the provided documentation, the white glass with gold crown for tooth #3 is not medically necessary for the patient. From the documentation provided, there is not any evidence of decay under the crown of tooth #3 nor any decay associated with tooth #3. As there is no decay, the current restoration does not require replacement. The tooth margins are without defect and replacement of the current restoration is not supported as medically necessary.