Diagnosis: Dental Problems.
Treatment: White Glass with Metal Crown, Tooth 18.

The insurer denied White Glass with Metal Crown, Tooth 18. The health plan's determination is overturned.

The patient is a male who presents for evaluation and treatment of tooth #18. Provided for review are previous letters of appeal and denial, full mouth radiographic images, one page of American Dental Association (ADA) claim forms and explanation of benefits. In question is the medical necessity of White Glass with Metal Crown, Tooth 18.

The White Glass with Metal Crown, Tooth 18 is medically necessary for this patient.
From the radiographic images provided the tooth is missing a majority of the clinical crown including the cusps and internal structure which requires replacement with a full coverage restoration. The tooth in question does in fact have an opposing tooth and is important for mastication. Therefore, a White Glass with Metal Crown, Tooth 18 is medically necessary for this patient.