Dental Caries: when insurers say no, reviewers often say yes

Where the denial was overturned

The parent of a one-year-old female enrollee has requested general anesthesia in a hospital or surgery center setting for treatment of the enrollee’s dental caries requiring pulpectomy. Findings: The physician reviewer found that coverage for general anesthesia in a hospital or surgery center setting is medically necessary for the patient’s dependent dental services. The patient has severe disease requiring extensive dental surgery. The patient is a one-year-old without fully developed oropharyngeal reflexes to protect the airway. General anesthesia provides a safe and effective setting for the dental surgery. General anesthesia also provides a controlled setting in which the patient’s airway is protected from excessive secretions and aspiration which can potentially put the patient at risk for respiratory distress.

Nature of Statutory Criteria/Case Summary: The guardian of an enrollee has requested general anesthesia for dental procedures for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that the request for general anesthesia for dental procedures is medically necessary in this clinical setting. General anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice. General anesthesia is often employed to facilitate extensive dental treatment particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting. The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for pediatric patients.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for dental general anesthesia. Findings: The physician reviewer found that General anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice. General anesthesia is often employed to facilitate extensive dental treatment particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting. Typically, the combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for some pediatric patients. Upon review of the medical record, there is clear documentation of the need for extensive dental work for this patient.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for general anesthesia (CPT 00170 and 41899) for dental procedures. The American Academy of Pediatric Dentistry states that indications for general anesthesia include “patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability.” The American Dental Association (ADA) supports deep sedation or general anesthesia for mentally or physically challenged patients (Cote, et al.). In this case, the patient requires placement of amalgam fillings, resin, and therapeutic pulpectomy. However, there is a lack of documentation from the providers to support an indication for general anesthesia for the performance of these procedures. There is no documentation of previous difficulty with dental procedures.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for dental caries was denied, the published record says the denial is worth fighting.