202302-159639
2023
Healthfirst Inc.
Medicaid
Dental Problems
Dental/ Orthodontic Procedure
Medical necessity
Overturned
Case Summary
Diagnosis: Dental decay
Treatment: White glass with metal crown for tooth 30 and ready-made post for filling for a crown for tooth 30
The insurer denied coverage for white glass with metal crown for tooth 30 and ready-made post for filling for a crown for tooth 30
The denial is overturned.
Based on the submitted documentation which includes copies of pretreatment, mid and post treatment periapical radiographs, narrative letter from the patient and insurer correspondence and coverage booklet, it appears that this patient presented to the dentist for comprehensive dental care. Endodontic therapy was recommended and completed on tooth #30 with additional recommendation of full coverage crown restoration on this tooth.
Upon review of radiographs, it supports the recommended treatment. Review of radiographs indicates a completed endodontic therapy #30. There is ample coronal structure remaining after the endodontic therapy. This tooth will have adequate residual coronal structure for support of crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of a post and core and crown on an endodontically treated tooth which would have an excellent long-term prognosis with the recommended treatment.
White glass with metal crown for tooth 30 and readymade post for filling for a crown for tooth 30 is considered medically necessary for this patient.
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.
The medical necessity for white glass with metal crown for tooth 30 and ready-made post for filling for a crown for tooth 30 is substantiated.