Diagnosis: Mild gingivitis, mild to moderate localized bone loss.
Treatment: D2751 white glass with metal crown tooth 20.

The insurer denied coverage for D2751 white glass with metal crown tooth 20.

The denial is upheld.

Upon review of the documentation provided which includes copy of full mouth series radiographs and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended full coverage crown for tooth #20. The insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service and therefore the service does not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is a copy of full mouth series radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting #20 based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental service as enumerated above and therefore the crown is deemed not medically necessary.

The documentation is insufficient to justify or substantiate the treatment.

The healthcare plan acted reasonably and with sound medical judgement in the best interest of the patient.

The insurer's denial of coverage for D2751 white glass with metal crown tooth 20 is upheld. Medical Necessity is not substantiated.