Summary
Diagnosis: Severe periodontal bone loss Treatment: D4263 bone replacement graft - retained natural tooth - first site in quadrant and D4266 guided tissue regeneration - resorbable barrier per site. The insurer denied coverage for D4263 bone replacement graft - retained natural tooth - first site in quadrant and D4266 guided tissue regeneration - resorbable barrier per site. The denial is overturned. This is a female patient who presented for evaluation and treatment in the area of tooth #30 which was deemed non-maintainable due to periodontal concerns and significant bone loss. The dentist recommended extraction of tooth #30 and placement of a graft and resorbable barrier membrane for ridge preservation. The insurer denied this service stating that the code submitted was incorrect and further the clinical circ*mstance and services requested does not fulfill the insurer's medical/dental criteria for approval. Based on the radiographic images, it is noted that tooth #30 is non maintainable due to severe periodontal bone loss. To maintain ridge height for future prosthetic rehabilitation especially with an endosteal implant in the area, the dentist has recommended the aforementioned grafting procedure and membrane. Ridge preservation procedures with bone grafting are an accepted standard of care service in dental practice and substantiated by peer reviewed literature. As this is a standard treatment, the graft and membrane procedure for ridge preservation is deemed dentally/medically necessary. Further, the clinical circ*mstance fulfills the insurer's medical necessity criteria for approval of these services. However, the insurer is correct in that the procedure code submitted was incorrect as tooth #30 was extracted and the code submitted to the insurer is for grafting with a retained natural tooth. The appropriate code that the dentist should have submitted was D7953. The decision should modify denial and approve coverage for bone graft (D7953) and D4266 guided tissue regeneration resorbable barrier per site as dentally necessary as they would be a standard of care services in preparation of an extraction site for endosteal implant placement and would be covered services as per the plan's criteria. The health plan did not act reasonably with sound medical judgement and in the best interest of the patient. Bone replacement graft and D4266 guided tissue regeneration resorbable barrier per site are considered medically necessary for this patient. The carrier's denial of coverage for D4263 bone replacement graft - retained natural tooth - first site in quadrant and D4266 guided tissue regeneration - resorbable barrier per site should be modified: Correct code from D4263 to D7953; Approve D7953 and D4266.
References
1) Avila-Ortiz G, Chambrone L, Vignoletti F. "Effect of Alveolar Ridge Preservation Interventions Following Tooth Extraction: A Systematic Review and Meta-Analysis." J Clin Periodontal. 2019 Jan 9. 2) Avila-Ortiz G, Elangovan S, Kramer KW, Blanchette D, Dawson DV "Effect of alveolar ridge preservation after tooth extraction: a systematic review and meta-analysis." J Dent Res. 2014 Oct;93(10):950-8. 3) Bassir SH, Alhareky M, Wangsrimongkol B, Jia Y, Karimbux N. "Systematic Review and Meta-Analysis of Hard Tissue Outcomes of Alveolar Ridge Preservation." lnt J Oral Maxillofac Implants. 2018 Sep/Oct;33(S). 4) Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M.Surgical protocols for ridge preservation after tooth extraction. A systematic review. Clin Oral implants Res. 2012 Feb;23 Suppl 5:22-38. 5) Stumbras A, Kuliesius P,Januzis G, Juodzbalys G. "Alveolar Ridge Preservation after Tooth Extraction Using Different Bone Graft Materials and Autologous Platelet Concentrates: a Systematic Review." J Oral Maxillofac Res. 2019 Mar 31;10(1).
