Diagnosis: Gingival Recession.

Treatment: D2740, porcelain crown to tooth 7.

The insurer denied coverage for D2740, porcelain crown to tooth 7. The denial is overturned.

Based on the submitted documentation which includes copies of bitewing and periapical radiographs, narrative letter from the dentist and insurer correspondence, it appears that this patient presented for dental care. A failing long ­standing crown restoration, was noted on #7 which exhibited gingival recession. Currently the dentist is requesting replacement of the crown due to periodontal concern and crown margin exposure leading to tooth sensitivity.

Review of radiographs supports the recommended treatment. Tooth #7 exhibits a crown with open margins on both the mesial and distal aspects of the tooth as well as possible recurrent caries, consistent with a failing existing restoration. There is ample coronal structure remaining. This tooth will have adequate residual coronal structure for support of a replacement crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be replacement crown which would have an excellent long-term prognosis with the recommended treatment.

Porcelain crown to tooth 7 is medically necessary as the radiographic documentation supports this service, and this service would be a standard of care in general dental practice.

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

The insurer's denial of coverage for D2740, porcelain crown to tooth 7 is overturned. Medical necessity is substantiated.