Diagnosis: Dental Disorder.
Treatment: porcelain crown for #14, and core buildup for #14.
The insurer denied a porcelain crown for #14, and core buildup for #14.
The determination is upheld.


The patient presented for the treatment of tooth number (#)14. Provided for review are a single periapical film, single bitewing film, multiple dental claim forms, as well as previous denials and health plan language.
Previous denials have been on the basis that the tooth does not appear to have decay or injury.
At issue is the medical necessity of the treatment of porcelain crown (2740) for #14, and core buildup (2950) for #14.

No, based on the provided documentation there is no evidence of medical necessity for the treatment of porcelain crown (2740) for #14, and core buildup (2950) for #14.
There is no provided diagnosis, no evidence of decay, no evidence of the presence of decay that requires a restoration beyond that of a direct restoration. There is no radiographic or clinical evidence of decay, nor any decay that would require a buildup or crown. There are also no clinical notes with any diagnosis of any decay to necessitate any treatment.