Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Dental Disorder
Treatment: Cleaning inside roots of a back tooth (root canal) for tooth # 14, Cleaning inside roots of premolar tooth (root canal) for tooth #12, Post and hard materiel under cap for teeth #s 12 and 14 and tooth-colored with metal underneath (crown) teeth #s 12, 14 and 19.
The insurer denied Cleaning inside roots of a back tooth (root canal) for tooth # 14, Cleaning inside roots of premolar tooth (root canal) for tooth #12, Post and hard materiel under cap for teeth #s 12 and 14 and tooth-colored with metal underneath (crown) teeth #s 12, 14 and 19.
The determination is overturned.

This is a male patient who presented for the treatment of teeth number (#) 12, 14, and 19. Provided for review are letters of appeal and denial, a letter from his Medical Doctor (MD), radiographic images of the teeth in question, and health plan language. At issue is the medical necessity of the treatment of molar root canal treatment (3330) #14, porcelain fused to high noble metal crown (2750) #12,14,19, post and core (2952) #12,14, and endodontic therapy premolar (3320) #12.

The treatment of molar root canal treatment (3330) #14, porcelain fused to high noble metal crown (2750) #12,14,19, post and core (2952) #12,14, and endodontic therapy premolar (3320) #12 is all medically necessary for the patient. As there is infection affecting the pulp of #14 and # 12, there is a diagnosis of irreversible pulpitis. In any situation where the patient has the diagnosis of irreversible pulpits, as long as the tooth is restorable, there is the requirement to treat the pulpitis through removal of the infected nerve, artery, vein, as well as the canal tooth structure, irrigate with sodium hypochlorite, and fill with gutta percha medicament as this is the only therapy that will treat the diagnosed pathology. This is a root canal. If the therapy is not done, the pulpal infection can spread to the surrounding bone, which can lead to the presence of an abscess, with an array of sequential systemic sequela. Hence, based on the diagnosis of irreversible pulpits alone, the therapy of root canal therapy is indicated. As the teeth are restorable, and as there will be a significant amount of tooth structure removed in order to cleanup the infected pulp, core buildup and crowns are necessary as replacements of tooth structure. Therefore, the entire treatment of molar root canal treatment (3330) #14, porcelain fused to high noble metal crown (2750) #12,14,19, post and core (2952) #12,14, and endodontic therapy premolar (3320) #12 is medically necessary.