Diagnosis: Dental Issues.
Treatment: Nerve Treatment on Molar Tooth for Tooth 31, D4341 Deep Gum and Root Cleaning for Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant and Upper Right Quadrant.

The insurer denied the Nerve Treatment on Molar Tooth for Tooth 31, D4341 Deep Gum and Root Cleaning for Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant and Upper Right Quadrant. The health plan's determination is overturned.

The patient is a female who presented for evaluation and treatment of tooth number 31 as well as full mouth periodontal therapy. Provided for review are previous letters of appeal and denial, full mouth radiographic images, and one page of claim forms. In question is the medical necessity of the planned treatment of (2791) base metal crown, (3330) root canal therapy, (4341) Scaling and root planning (SCRP) for the upper right (UR) quadrant, upper left (UL) quadrant, lower left (LL) quadrant and the lower right (LR) quadrant.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment nor in the best interest of the patient.

The requested health service/treatment of nerve treatment on molar tooth for tooth number 31, D4341 deep gum and root cleaning for the lower left quadrant, lower right quadrant, upper left quadrant and upper right quadrant is medically necessary for this patient. Previous denials for root canal therapy have been on the basis that only teeth that serve as critical abutments for an existing partial denture or bridge are eligible. This is not based on any medical science nor any scientific basis for lack of necessity.

There is radiographic evidence of decay resulting in exposure of the pulp on the mesial in the same location where the patient has lost a cusp, resulting in the need to remove the infection from the pulp with a root canal and restore the tooth with an indirect restoration, such as a crown, as direct restorations are contraindicated in cuspal loss. Denials of the SCRP have been on the basis that there is not significant bone loss; however, there is evidence of loss of lamina dura along the bone peeks between the majority of the teeth, as well as angular bone defects consistent with the presence of active periodontal disease, serving as proof of the medical necessity of the treatment of scaling and root planing.