Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Partial Edentulism.
Treatment:  Dental Procedure/Dental Implants.

The health plan denied the requested dental procedure.  The health plan's determination is upheld.

The patient is a female, who presents to the office for treatment of teeth #4,6,11,22,27 with dental implants and ridge augmentation in an unspecified location.  From the provided documentation the patient is taking medications including Alogliptin for her diabetes, Enalapril Hydrocholorothiazide for hypertension, Glipizide for her diabetes, Atorvastatin for hyperlipidemia, and Metformin for diabetes.

Previous denials have been on the basis that implants are only covered benefits if a denture does not address the patients issue and that records show that a denture can address the patient's issue.  There have been arguments stating that the applicant cannot have a denture due to the time involved in delivery of a denture and the argument that she is suffering from hypoglycemic episodes due to an inability to eat.  From the radiographs the patient still has teeth #'s 3,4,5,6,11,13,14,20,21,27,28,29, and 32.  There are no clinical notes, no notes of any clinical examination of the patient, no diagnosis, no explanation of the ultimate restorative plan or direction, and no indication of the patient's hemoglobin A1C (HbA1C).

At issue is the medical necessity of the of the requested service.

I uphold in whole the health plan's determination of medical necessity.

No, the requested service of treatment of teeth #4,6,11,22,27 with dental implants and ridge augmentation in an unspecified location is not supported by the provided documentation.  As there are no clinical notes, no notes of any clinical examination or evaluation of the patient, no diagnosis, no explanation of the ultimate restorative plan or direction, and no indication of the patients HbA1C, there is no support of the need for the requested therapy.

There is no diagnosis for the patient's dental condition to explain the reason why she cannot have a denture, nor why or where the grafting is necessary, what the final prosthesis would be that is attached to the implants, nor any plan beyond the position of the implants themselves.  The argument that the denture cannot be done due to the time necessary to complete the denture is not correct, as any dental prosthesis, implant supported or not, will only be delayed by the need for additional surgeries and grafting, as well as the implant surgeries themselves.  The argument that the patient would not have removed her teeth if she knew that implants are not covered is not correct, as teeth are not extracted in order to place implants; here the teeth were extracted due to the periodontal loss and loss of bone as evidenced by the radiographs; the replacement of the teeth can occur in many different ways.  As the patient is taking many medications to control her diabetes, as it has been reported that she has had multiple hypoglycemic episodes, and as she has radiographic evidence of severe bone loss throughout her maxilla and mandible, it is very likely that her blood sugar is not controlled, which creates a contraindicated state for grafting and implant therapy.  The HbA1C was not provided for the patient.  Grafting and dental implants in diabetic patients who do not show evidence of being well controlled has a high incidence of early failure as well as periodontitis, as well as failed grafting.