202104-137318
2021
Healthfirst Inc.
Medicaid
Dental Problems
Dental/ Orthodontic Procedure
Medical necessity
Upheld
Case Summary
Diagnosis: Pre-molars.
Treatment: Surgical removal of teeth #21 and #28.
The insurer denied the Surgical removal of teeth #21 and #28.
The denial is upheld.
The patient is a male patient who is having pre-molars removed. Surgical extractions (D7210) have been billed for teeth #21 and #28, and have been denied.
No, the requested health service is not medically necessary.
The radiograph shows that the teeth are intact with no caries. However, even if the crown of the tooth fractures during the extraction, and the removal of the exposed root is elevated and/or removed with forceps even if a periosteal flap is completed, the appropriate American Dental Association (ADA) code is D7140, extraction, erupted tooth or exposed root (elevation and forceps removal). If, in addition to the flap, bone is removed, or the roots are sectioned in order to remove the roots, then the surgical extraction code is D7210.
Code D7210 would only be justified with an operative report showing that bone removal was required. There is no such documentation evident in the records that were submitted for review. Therefore, given that the patient did not meet the requirements for code D7210 for teeth #21 and #28, D7210 for teeth #21 and #28 was not medically necessary. The teeth could have been extracted under a less intensive code.
D7210 would require an operative report showing that bone removal was required. There is no such documentation for this patient.