Diagnosis: Cavities

Treatment: Outpatient Dental services (cavities fixed and teeth removed)

The insurer denied coverage for Outpatient Dental services (cavities fixed and teeth removed)

The denial is overturned

Based on the submitted clinical documentation including narrative letters from the child's dentist and clinical notes/dental charting, it appears this child with dental anxiety presented for dental treatment and would require multiple and extensive dental services. Due to anxiety contributing to poor compliance in the outpatient setting, it was recommended that all dental treatment be performed under deep sedation in an outpatient ambulatory operating room setting. The insurer has denied services as not being necessary as the situation does not meet their stipulated criteria. The patient's dentist is appealing the denial on behalf of the patient.

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 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 reversed. 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 Outpatient Dental services (cavities fixed and teeth removed) is substantiated.