Diagnosis: Tooth fracture. Treatment: D2954 tooth #14; D2750 tooth #14. The insurer denied the D2954 tooth #14; D2750 tooth #14. The denial is overturned. The patient is a female requesting dental benefits on tooth #14 (D2954 - prefabricated post and core; D2750 - crown). The patient presented with bleeding and swollen gums. The patient presented with fracture to tooth #14; she stated she was experiencing pain upon chewing/biting down. Tooth #14 already had a large amalgam filling covering approximately 85 percent of the occlusal surface. X-rays, photos, and clinical consultation were performed. The Health plan denied the crown due to no decay or injury present on tooth #14. The provider appealed the claim based on the condition of tooth #14. Yes, the proposed treatment of a prefabricated post and core and crown on tooth #14 was medically necessary. Due to the very large existing filling and the area of fracture on the lingual aspect of tooth #14, a prefabricated post and core and crown is the standard of care to prevent the tooth from further fracture and restore function and comfort to this patient. No, the health plan did not act reasonably with sound medical judgement and in the best interest of the patient as the prefabricated post and core and crown on tooth #14 was medically necessary. Given the condition of tooth #14 and the patients symptoms, if left untreated, this would only lead to further fracture and may eventually lead to tooth loss. The tooth may further fracture in a manner such that it becomes non-restorable and would need to be extracted.

1) Contemporary Fixed Prosthodontics--4thed by Stephen Rosenstiel, Martin Land, Junhei Fujimoto. (Mosby 2006).