Diagnosis: periodontal pocketing

Treatment: deep gum and root cleaning.

The insurer denied coverage for deep gum and root cleaning.

The denial is upheld.



Based on the submitted documentation which includes copies of periodontal charting, panoramic radiograph and insurer correspondence, it appears that this patient presented for evaluation for dental services and periodontal therapy. The dentist reported periodontal chartings indicating 2-5 millimeter (mm) generalized periodontal pocketing. The recommended treatment was scaling and root planning of all four quadrants. The insurer has denied the service as the information provided does not show evidence of moderate to severe periodontal disease or other clinical or radiographic criteria to justify the services such as bone loss and therefore does not meet clinical criteria to support scaling and root planning. The patient is appealing.

Upon review of the submitted documentation, both the radiographs and periodontal probing depths there is minimal if any loss of alveolar bone height affecting these teeth. The 5 mm increased pocket depths likely represent pseudo pocketing due to superficial calculus accumulation and poor oral hygiene. There is minimal significant periodontal probing with no periodontal probing over 5 mm depth. The insurer has correctly applied the clinical criteria in denying scaling and root planning services.

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 deep gum and root cleaning, All Quadrants is not substantiated.