Dent/Orthodont Proc denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the following components (osteotomy, mandible, segmental; face bone graft; nasal, maxillary or malar areas (includes obtaining graft); and/or lower jawbone graft; mandible, includes obtaining graft), for the requested orthognathic surgical procedure.Findings: The physician reviewer found that etiology of maxillofacial skeletal deformities may be either congenital or acquired. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional and/or degenerative problems. The records provided for review document that this patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics alone.

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.

Where the denial was upheld

Physician 1: The patient is a 35-year-old female with temporomandibular joint dysfunction and associated head and neck pain. Treatment with physical therapy produced significant improvement in symptoms. The submitted evidence does not demonstrate that she has been treated with a combination of dental occlusal splinting, analgesics and physical therapy. Orthotic splinting and occlusal equilibration has not been performed and the patient’s symptoms have recurred.A request has been made for authorization and coverage for an electromyography (EMG).

Nature of Statutory Criteria/Case Summary: An enrollee has requested dental services for an emergent or urgent basis. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention. California law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient’s health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving dent/orthodont proc, then check the rights and deadlines that apply to your plan.