Diagnosis: Dental Cavities

Treatment: Professional Services, dental procedure (41899 x 32)

The insurer denied coverage for Professional Services, dental procedure (41899 x 32)

The denial is overturned

Based on the submitted clinical documentation including narrative letter, pretreatment clinical images, in addition to insurer correspondence, it appears this child with history of multiple cardiac surgeries, presented with severe dental decay, extensive dental needs, and situational anxiety for dental treatment. Due to poor compliance in the outpatient setting, it was recommended that all dental treatment be performed under deep sedation/general anesthesia. The insurer has denied services as not being covered under the benefit plan as they do not meet Dental Anesthesia and Facility Services guidelines.

Upon review of the documentation submitted and as enumerated above, this patient had significant dental needs that would be difficult to provide in the outpatient setting due to significant dental disease, age of the patient and documented poor compliance/anxiety. Therefore, it was recommended that all treatment be performed in a controlled setting under deep sedation/general anesthesia. This provides the benefit of completing all dental needs at one time and anesthesia. This is a standard of care treatment for this clinical situation when dealing with pediatric patients. This treatment is supported in the literature (see below). Further, the treatment plan as recommended fulfills and meets all the insurer's medical necessity criteria. As such the services recommended are considered medically necessary.

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 the Professional Services, dental procedure (41899 x 32) is overturned. Medical Necessity is substantiated.