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

The insurer denied extraction of tooth # 1 and # 16, and general anesthesia each 15 minutes.
The denial is partially overturned.

The patient is a female who has been approved for removal of impacted tooth 32 and 30 minutes of general anesthesia. Extraction of tooth #1 and tooth #16 have been denied as there is no documentation of severe pain in these teeth, or that they will not erupt on their own. 30 minutes of additional anesthesia has been denied. The subject under review is the medical necessity for extraction of impacted tooth with bone, tooth 1, 16 and general anesthesia.

The health plan's determination is overturned in part.

The removal of tooth #1 and tooth 16 are medically necessary. The additional anesthesia is not medically necessary without an anesthesia record that documents the need for the additional time.

The American Association of Oral and Maxillofacial Surgeons (AAOMS) Parameters of Care states that an impacted third molar that is so positioned that it will probably not erupt by the middle of the third decade constitutes pathology with dental and medical consequences. To limit known risks and complications associated with surgery, it is medically appropriate and surgically prudent to remove impacted third molars before the middle of the third decade and prior to complete root development. An impacted tooth with completed root formation that is totally covered by bone in a patient beyond the third decade that does not meet the following indications for removal should be monitored for change in position and/or development of pathology, which may then indicate its removal. The patient meets these criteria as the patient has impacted wisdom teeth that are so positioned that they will probably not erupt by the middle of the third decade. In addition, even if the teeth erupt, they will be unopposed and nonfunctional.

Extraction of teeth # 1 and # 16 are medically necessary and is overturned. General anesthesia - each 15 minutes is not medically necessary and is upheld.