Diagnosis: dental problems.

Treatment: D6241 false tooth for bridge, Tooth 28; D6751 white glass with metal cap for bridge, Tooth 27; D6751 white glass with metal cap for bridge, Tooth 29; D6751 white glass with metal cap for bridge, Tooth 30; 06751 white glass with metal cap for bridge, Tooth 31 D6751 white glass with metal cap for bridge, Tooth 31.

The insurer is denied coverage for D6241 false tooth for bridge, Tooth 28; D6751 white glass with metal cap for bridge, Tooth 27; D6751 white glass with metal cap for bridge, Tooth 29; D6751 white glass with metal cap for bridge, Tooth 30; 06751 white glass with metal cap for bridge, Tooth 31 D6751 white glass with metal cap for bridge, Tooth 31.

The denial is overturned.

This female patient has a history of dental problems

Upon review of the documentation, in particular the radiograph it is evident that the preexisting bridge was failing. To restore function to the right mandibular dentition, in this case since the patient has pre-existing fixed bridge, replacement with a fixed prosthesis spanning #27-31site as recommended is the standard of care dental treatment in general dental practice. As the dentition is already restored with a fixed bridge prosthesis the only treatment that would be considered an appropriate for replacement of the current fixed bridge is another.

Reverse denial and approve coverage for D6241 false tooth for bridge, tooth 28; D6751 white glass with metal cap for bridge, tooth 27; D6751 white glass with metal cap for bridge, tooth 29; D6751 white glass with metal cap for bridge, tooth 30; D6751 white glass with metal cap for bridge, tooth 31 as medically necessary at this would be the standard of care dental treatment in clinical practice.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the D6241 false tooth for bridge, Tooth 28; D6751 white glass with metal cap for bridge, Tooth 27; D6751 white glass with metal cap for bridge, Tooth 29; D6751 white glass with metal cap for bridge, Tooth 30; 06751 white glass with metal cap for bridge, Tooth 31 D6751 white glass with metal cap for bridge, Tooth 31 is overturned. The medical necessity is substantiated.