Diagnosis: Pulpitis
Treatment: root canal therapy (3310) for tooth #11.
The insurer denied root canal therapy (3310) for tooth #11.
The determination is overturned.


The patient presented for evaluation and treatment of tooth number (#)11 with root canal treatment (3310). Provided for review are previous letters of appeal and denial, a narrative from her provider explaining radiographic bone levels and pulpal diagnosis of tooth #11, full mouth radiographic and single periapical images from unknown dates, one page of American Dental Association (ADA) claim forms, periodontal indices, and clinical notes. At issue is the medical necessity of the planned treatment of root canal therapy (3310) for tooth #11.
The requested service of nerve treatment on front tooth #11 is medically necessary for this patient. In any situation where the patient has the diagnosis of irreversible pulpitis, as long as the tooth is restorable, as it is here, there is the requirement to treat the pulpitis through removal of the infected nerve, artery, vein, as well as the canal tooth structure, irrigate with sodium hypochlorite, and fill with gutta percha medicament as this is the only therapy that will treat the diagnosed pathology. This is a root canal. If the therapy is not done, the pulpal infection can spread to the surrounding bone, which can lead to the presence of an abscess, with an array of sequential systemic sequela. Therefore, based on the diagnosis of irreversible pulpitis alone, the therapy of root canal therapy is indicated.