Diagnosis: Fracture teeth x 2
Treatment: Post and hard material under cap (post and core) for tooth # (numnber) 8 and tooth colored cap for teeth #'s 8 and 9
The insurer denied coverage for post and hard material under cap (post and core) for tooth #8 and tooth colored cap for teeth #'s 8 and 9.
The denial is upheld.

Upon review of the submitted documentation which includes copies of panoramic radiograph and periapical radiographs and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment presumably secondary to fracture of teeth # (number) 8 and 9 with pain. Based on the documentation, post and crowns were recommended. The insurer has denied the services stating that these services are not medically necessary treatment as the clinical documentation does not support the requested services. The patient is appealing.

Based on the submitted objective information for review, which consists solely of the radiographic examinations, it is difficult to discern any radiographic issues as the quality of the radiographs is poor/inadequate. As this is the case, and there is no other objective clinical documentation provided for review, the radiographic documentation does not support the 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.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for post and hard material under cap (post and core) for tooth #8 and tooth colored cap for teeth #'s 8 and 9 is not substantiated.