Diagnosis: Severe dental anxiety.
Treatment: intravenous moderate (conscious) sedation/analgesia (D9239 and D9243).
The insurer denied coverage for intravenous moderate (conscious) sedation/analgesia.
The denial is overturned.

Based on the submitted clinical documentation including narrative letter and clinical notes, it appears this child with severe dental anxiety presented for dental treatment requiring an extraction of a tooth. Due to anxiety contributing to poor compliance in the outpatient setting, it was recommended that all dental treatment be performed under deep sedation by oral surgery. The insurer has denied services as not being necessary as the situation does not meet their stipulated criteria.

Upon review of the documentation submitted and as enumerated above, this patient had dental needs that would be difficult to provide in the outpatient setting due to the age of the patient and poor compliance/anxiety. Therefore, it was recommended that treatment be performed in a controlled setting under deep sedation/general anesthesia. This provides the benefit of completing dental needs and anesthesia assures patient compliance. This is a standard of care treatment for this clinical situation when dealing with pediatric patients. This treatment is supported in the literature (see below). Further, the treatment plan as recommended fulfills and meets all of the insurer's medical necessity criteria. As such the services recommended are considered medically necessary.

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 intravenous moderate (conscious) sedation/analgesia - first 15 minutes (D9239) and Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minutes increment (D9243) is substantiated.