Diagnosis: Dental caries
Treatment: Nerve treatment and post on teeth 3, 4, 7, 10, 12, 13, and crown on teeth 2, 3, 4, 7, 8, 9, 10, 12, 13, 15, 29, and 30
The insurer denied coverage for nerve treatment and post on teeth 3, 4, 7, 10, 12, 13, and crown on teeth 2, 3, 4, 7, 8, 9, 10, 12, 13, 15, 29, and 30
The denial is upheld


Upon review of the submitted documentation which includes copies of full mouth series radiographs and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment. Based on the documentation, multiple endodontic procedures and post and crowns were recommended for multiple teeth in all 4 quadrants. The insurer has denied the services stating that these services are not medically necessary treatment as the clinical documentation does not support it, and further there is extensive decay, and high risk of new decay. The patient is appealing.

Based on the submitted information for review, particularly the radiographic examination, there is evidence of multiple carious teeth; however, there does not appear to be any caries or odontogenic or periodontal pathology on numerous additional teeth that the doctor has recommended for treatment. The clinical and radiographic documentation do not support the extensive dental treatment recommended by the dentist. There are no dental treatment notes, no dental charting, nor periodontal charting provided for review. As the documentation is inadequate to support the treatment, these services are considered not medically necessary.

Uphold denial for nerve treatment and post on teeth 3, 4, 7, 10, 12, 13 and crown on teeth 2, 3, 4, 7, 8, 9, 10, 12, 13, 15, 29 and 30 as the provided documentation for review is inadequate and did not support the extensive treatment recommended.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for nerve treatment and post on teeth 3, 4, 7, 10, 12, 13, and crown on teeth 2, 3, 4, 7, 8, 9 ,10, 12, 13, 15, 29, and 30 is not substantiated.