Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Facial pain, temporomandibular joint (TMJ) disorder.
Treatment: D6010 Implant Placement, Tooth 3, 4, 6, 13, 14 and Tooth 30; D6057 Custom Abutment, Tooth 3, 4, 6, 13, 14, and Tooth 30; D6065 Implant Supported Porcelain/Ceramic Crown, Tooth 3, 4, 6, 13, 14 and Tooth 30; D7951 Sinus Augmentation, Upper Left Quadrant; D7951 Sinus Augmentation, Upper Right Quadrant.

The insurer denied the D6010 Implant Placement, Tooth 3, 4, 6, 13, 14 and Tooth 30; D6057 Custom Abutment, Tooth 3, 4, 6, 13, 14, and Tooth 30; D6065 Implant Supported Porcelain/Ceramic Crown, Tooth 3, 4, 6, 13, 14 and Tooth 30; D7951 Sinus Augmentation, Upper Left Quadrant; D7951 Sinus Augmentation, Upper Right Quadrant.  The denial is overturned.

The patient is a female. The request is for dental benefits for teeth #3, 4, 6, 13, 14, 30. The request is for implant placement, custom abutments, implant supported porcelain crowns, and sinus augmentation of the upper left and upper right side. 

The patient presents with several missing teeth, facial pain and temporomandibular joint (TMJ) disorder. The patient gives a history of using upper and lower partial dentures, but is unable to chew effectively with them. She also has developed severe pain and discomfort from having to use her tongue to alleviate the pressure off her front teeth when she sleeps. Of note, removable partial dentures are to be removed at night. 

The health plan denied the claim on the basis that the implants are not medically necessary since the patient does not have a medical condition requiring replacement of missing teeth with implants, and thus related services were deemed not medically necessary. The patient appealed the claim because she feels that her pain and medical conditions should be taken into consideration to be approved for implants.

Yes, the proposed treatment of implant placement, custom abutments, implant crowns and bilateral maxillary sinus augmentation is medically necessary.

A patient typically has three options for replacing missing teeth. These include implants, dentures and crown and bridge (fixed prosthodontics).  In this case, based on the number and position of missing teeth, this patient only has the choice of implants or dentures because one must have teeth anterior and posterior to the missing space for fixed prosthodontics to be utilized. This patient does not meet the criteria for fixed prosthodontics.

The patient has given a history of partial denture use that has not been effective for her chewing and does not give the necessary bite support that is required for optimum function. Therefore, her only remaining option is to have implants placed that would provide optimum chewing ability and stability to the dentition that most closely resembles that of the patient's original dentition. Based on the above, the implants and related services below are medically necessary:  1) D6010 Implant Placement, Tooth 3, 4, 6, 13, 14 and Tooth 30, 2) D6057 Custom Abutment, Tooth 3, 4, 6, 13, 14, and Tooth 30, 3) D6065 Implant Supported Porcelain/Ceramic Crown, Tooth 3, 4, 6, 13, 14 and Tooth 30, 4) D7951 Sinus Augmentation, Upper Left Quadrant, and 5) D7951 Sinus Augmentation, Upper Right Quadrant.

No, the health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.

The patient is missing most of her posterior teeth bilaterally; these teeth are essential for optimum chewing function, for maintaining the stability of the remaining teeth in the arch and distributing the appropriate amount of biting forces equally across the dentition. When these forces are not evenly distributed, the result is typically facial pain, disorders of the temporomandibular joint (TMJ) and other pain in the head and neck region.

Neurological and other medical tests are reported to be negative, suggesting that the patient may be experiencing these issues based on the current status of her dentition. Proper digestion is intrinsically linked to the ability for proper chewing to take place, as digestion begins in the mouth. This is another reason why this patient needs to have a stable, sound option of teeth replacement.

Having stated the importance of replacing these teeth, by denying this claim the health plan is not acting in the best interest of the patient.