Impacted Teeth: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of a minor enrollee has requested reimbursement for general anesthesia in a hospital operating room setting during dental extraction surgery. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollee’s impacted teeth. A review of the records indicates the enrollee was diagnosed with impacted teeth. In an operative report, the enrollee’s provider noted that the enrollee had a disturbance of tooth eruption involving the secondary maxillary canines. The maxillary canines were horizontally impacted with crowns facing anteriorly. The roots of the adjacent teeth were close to the impacted teeth. The provider noted the procedure would be carried out in an operating room under general anesthesia due to the enrollee’s age and significant complexity of the procedure.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an additional two (2) units of sedation.Considering that deep sedation requires titration of medications, monitoring of vital, and postoperative observation, 30 minutes of sedation time are not enough, making the additional 30 minutes of sedation medically necessary in order to carry out the procedure and allow for the patient to not undergo stress during the procedure. Anxiety is a known trigger for asthmatic patients.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for general anesthesia services provided during wisdom teeth extraction. Findings: The physician reviewer found that The submitted documentation does not support that the services at issue were medically necessary. The American Academy of Pediatric Dentistry (AAPD) guidelines for general anesthesia outline four indications for general anesthesia (GA) in pediatric dentistry: 1) Patients exhibiting physical, intellectual, or medically compromising conditions, for which dental treatment under local anesthesia cannot be expected to provide a humane and successful result; 2) Patients demonstrating dental treatment needs for which local anesthesia is indicated, but is ineffective because of acute infection, anatomic variation or allergy; 3) An extremely uncooperative, fearful, anxious or uncommunic…

The parent of a minor enrollee has requested authorization and coverage for removal of teeth numbers 1 and 16. Findings: The physician reviewer found that the radiograph provided does not demonstrate any pathology associated with teeth numbers 1 or 16, and appears to show adequate space present to allow normal passive eruption of these teeth. The radiograph does not demonstrate etiological factors for pain caused by the presence of teeth numbers 1 and 16 other than the potential for the discomfort normally associated with tooth eruption. The morbidity risk associated with prophylactic extraction of third molars when not dentally necessary has led to a need to assess risk versus benefit of extractions where no pathology is demonstrated.

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 impacted teeth was denied, the published record says the denial is worth fighting.