Diagnosis: Dental caries
Treatment: Outpatient dental work to be done at the hospital
The insurer denied outpatient dental work to be done at the hospital
The determination is overturned.

The patient has a history of acute reaction to stress (F43.0), generalized anxiety (F41.1) and behavioral concerns (F98.9) and presented with severe dental caries. The current treatment plan includes tooth extractions and fillings, to be done in an operating room with anesthesia, based on the patient's medical history. At issue is the medical necessity of outpatient dental work to be done at the hospital.

Based on the radiographs provided, this patient needs the dental work done to prevent further pain, infection, or sepsis. The sequelae of infection and/or sepsis have been noted in pediatric cases with severe dental caries. As noted in peer reviewed literature, the proportion of children with sepsis increases markedly with caries experience. Pediatric patients with the following medical diagnoses (F43.0, F41.1, F98.9) that also present with severe dental caries (K02.9) are best treated in an operating room with anesthesia to ensure safe delivery of care. The dental care is provided more efficiently as it is completed during one visit. The treatment presented by the provider is congruent with the diagnostic images and medical history for the patient and the patient's treatment is supported due to medical necessity and prevention of further medical complications for the patient.