Diagnosis: failing dentition and endodontically treated teeth in the left maxilla

Treatment: D6750, retainer crown on teeth 12 and 14 and pontic D6240 on tooth 13

The insurer denied coverage for D6750, retainer crown on teeth 12 and 14 and pontic D6240 on tooth 13

The denial is overturned

Upon review of the submitted documentation which includes copies of periapical radiographs, narrative letter from the patient and insurer correspondence, it appears that this patient presented for dental care with a failing dentition and endodontically treated teeth in the left maxilla. Recommended treatment was to place a fixed bridge prosthesis spanning teeth #12-14 with pontic at #13 site. The insurer has denied this service stating that medical necessity criteria are not met. The patient is appealing.

Upon review of the documentation, on radiograph radiographs it is evident that the teeth have had endodontic therapy and there is an edentulous space. To restore function to the maxillary dentition, placement of a fixed prosthesis spanning #12-14 site as recommended is the standard of care dental treatment in general dental practice especially on endodontically treated abutment teeth. There is adequate coronal structure to maintain a bridge and there does not seem to be biologic width issues.

Coverage for D6750 retainer crown on teeth 12 and 14 and pontic D6240 on tooth 13 is medically necessary as this would be the standard of care dental treatment in clinical practice.

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

The insurer's denial of coverage for D6750, retainer crown on teeth 12 and 14 and pontic D6240 on tooth 13 is overturned. Medical Necessity is substantiated.