Dental
Dental procedure

Diagnosis: teeth decay
Treatment: Crowns for Teeth #s 7, 18 and 30
The insurer denied Crowns for Teeth #s 7, 18 and 30. The health plan's determination is overturned.

The patient is a male who presents for evaluation and treatment of teeth # (number) 7,18 and 30. Provided for review are previous letters of appeal and denial, full mouth panoramic radiographic image, one page of American Dental Association (ADA) claim forms and health plan language. In question is the medical necessity of the crowns for teeth #7, 18 and 30 (D02751).

Crowns for Teeth #s 7, 18 and 30 are medically necessary for this patient. The teeth involved have an overall fair prognosis from the information provided and will be able to continue to provide form and function if restored with crowns. The rationale for extraction would lead the patient to having diminished posterior support and would be detrimental from a medical/dental perspective as tooth loss increases the load and strain on the remaining dentition. Dentures to not provide support and depend completely on the soft tissue for support, retention and stability, eventually leading to further tooth loss. As the teeth involved have decay and require full coverage restorations, the requested treatment is medically necessary.