Diagnosis: Dental Problems.
Treatment: Dental/Orthodontic Procedure.

The insurer denied dental procedure of Partial dentures, root canal, and crowns.
The denial was upheld.

This is a male patient who has a history of rectal cancer, status/post (s/p) chemotherapy. He is scheduled for upper and lower partial dentures, root canal treatment for #23 and crowns for #26, #27, #28 and #30 because the prognosis of the remaining teeth is not good.

At issue is the medical necessity of Plate replacing some upper and lower teeth (Partial dentures), cleaning inside roots of tooth (Root Canal) for tooth #23, tooth colored cap (Crown) for teeth #'s 26, 27 and 28 and metal cap (Crown) for tooth #30.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Plate replacing some upper and lower teeth (Partial dentures), cleaning inside roots of tooth (Root Canal) for tooth #23, tooth colored cap (Crown) for teeth #'s 26, 27 and 28 and metal cap (Crown) for tooth #30 is not medically necessary for this patient.

The notes state that the patient has a collapsed bite, and the vertical dimension must be opened, and partial dentures will be submitted for. There is not enough clinical documentation to determine if the treatment is medically necessary and appropriate. There is not a complete examination and treatment plan. In order to determine the appropriateness for treatment, a thorough examination and treatment plan is typically documented. The Panorex shows almost all the teeth have had root canal treatment and there are multiple non-restorable teeth. There is no documentation showing the pocket depths of the remaining teeth. #23 has extensive caries and a periapical lesion. Generally, the determining factors would be the periodontal examination and whether or not this tooth could be removed and replaced with a partial denture. In addition, the examination does not state which teeth are to be the abutment teeth. The notes do not contain this documentation or treatment plan.

Therefore, the treatment of Plate replacing some upper and lower teeth (Partial dentures), cleaning inside roots of tooth (Root Canal) for tooth #23, tooth colored cap (Crown) for teeth #'s 26, 27 and 28 and metal cap (Crown) for tooth #30 is not medically necessary.