Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial Trauma

Treatment: D6010 Implant Placement, Tooth 8 and 9 and D7950 Facial Surgery

The insurer denied coverage for D6010 Implant Placement, Tooth 8 and 9 and D7950 Facial Surgery 

The denial is upheld

The patient has a history of facial trauma following a bicycle injury years ago that affected his maxillary anterior teeth.  This accident resulted in the loss of his maxillary left central incisor (#9) and the need for root canal treatment of the maxillary right central incisor (#8).  Upon examination, a root fracture was noted on #8, necessitating its extraction as well. At the time of extraction, the surgeon noted that the buccal plate was deficient, the space for #9 was insufficient, and caries was present on other teeth as well.  The patient was treatment planned for a bone graft and implants to replace #8 and #9.  It was also noted by the oral surgeon that the patient would need orthodontic therapy to regain the space lost by the mesial drifting of the teeth into the space created by the premature loss of #9. 

An Orthodontist states that the patient completed orthodontic treatment to create suitable arch length (space) to replace both #8 and #9.  He further states that it is his opinion that a removable prosthesis is not an "appropriate option due to the patient's age." An additional letter from the patient's Pediatric doctor's office states that he cannot "bite into food," and "this is affecting his eating habit." It further states that the teeth will begin to shift if the dental problem is not addressed and that the child's emotional state is affected by the loss of his anterior teeth.  Though the Orthodontist's letter states that the treatment has been completed, a letter issued, written months later, states that the patient will require orthodontic treatment, operative treatment to address the carious lesions, bone grafting to replace the defective buccal bone, as well as implants.  It is the opinion of the practitioner that the patient would benefit from a "functional point of view" by replacing the teeth with the fixed prosthodontic option offered-implants versus a fixed partial denture, as this would lead to "premature tooth loss" in their professional opinion. 

In a case report specifically analyzing the long-term growth of the maxillae and portion of an anterior central incisor implant on a teenage male patient; the researchers found that at age twenty-five, the patient's growth had continued, causing a large discrepancy between the gingival margin at the implant collar and the cementoenamel junction (CEJ) of the adjacent teeth. (Rossi & Andreasen, 2003)  The study further states that the "alveolar bone growth in the area of the implant does not keep pace with the growth of the adjacent alveolus." (Rossi & Andreasen, 2003, p.117) 

Many proven replacement options exist for missing teeth and are dictated by many factors including the size and nature of the defect, the predictability of the surgical reconstruction of bone and soft tissue deficiencies, the experience of the treating implant team, the wishes or expectations of the patient, and perhaps other factors.  Based on the patient's age and the likelihood that he is continuing to experience growth up until age twenty-five, it would not be advisable or in the patient's best interests to replace the missing maxillary central incisors with implants at this time. Therefore the decision is upheld.

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

The insurer's denial of coverage for D6010 Implant Placement, Tooth 8 and 9 and D7950 Facial Surgery is upheld. Medical necessity is not substantiated.