Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia
Treatment surgical placement of implant body: endosteal implant, Tooth 3, 5, 12, 14, 19, 21, 28 and 30 (code D6010)
The insurer denied coverage for surgical placement of implant body: endosteal implant, Tooth 3, 5, 12, 14, 19, 21, 28 and 30 (code D6010)
The denial is upheld

Based on review of the submitted documentation which includes copies of panoramic radiograph, full mouth series radiographs, individual periapical radiographs, dental treatment notes, dental treatment records, periodontal records/ probings, medical notes in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentists and residents, at the patients request, recommending endosteal implants in areas as enumerated above, during treatment planning. The dentists are requesting implants over removable partial dentures presumably due to patients reported difficulty and pain with chewing. 

Comprehensive care has included periodontal services and periodontal maintenance, restorative treatment, and extractions. Over time the patient lost several teeth in the maxilla and mandible and currently exhibits oligodontia in both the maxilla and mandible. In this case, as regards implants, there appears to be two issues:1) Whether implants are the only acceptable option for this patient given reported difficulty with function or 2) whether another option such as removable partial dentures is appropriate.  

On reviewing the dental treatment notes, various treatment alternatives were broached with patient during treatment planning including removable partial dentures. Nowhere in the clinical notes does it document that the patient stated any issues with function. What is documented throughout the chart was that the patient was made aware on several occasions that removable partial dentures were an acceptable alternative to implants and that it was ultimately the patient who requested implants.  It is also stated that the patient was made aware that his insurance would likely not cover implant related services and any charges would be his responsibility. That removable partial dentures were an acceptable alternative was reiterated again in many notes. Therefore, it seems that overtime removable partial dentures remained a viable treatment for this patient. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures.

Further, the medical documentation provided does not support, justify, or substantiate the requested treatment.   Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are not medically necessary.

The health care plan acted reasonably and with sound medical judgement and in
the best interest of the patient.

The insurer's denial of coverage for surgical placement of implant body: endosteal implant, Tooth 3, 5, 12, 14, 19, 21, 28 and 30 (code D6010) is upheld. Medical Necessity is not substantiated.