Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing tooth 
Treatment: biologic materials, guided tissue regeneration, and bone graft performed on tooth number 30
The insurer denied coverage for biologic materials, guided tissue regeneration, and bone graft performed on tooth number 30.
The denial is upheld.

Based on review of the submitted documentation which includes copies of undated pretreatment and post implant placement panoramic radiographs, narrative letter from the Dentist, copy of intraoral photograph, photographs of the implant intraorally as well as photographs of the implant crown, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the #30 area. The dentist is recommending biologic materials, bone replacement graft and guided tissue regeneration prior to surgical placement of implant at the #30 site to restore function. The insurer has denied the services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant and related services are only covered when documented and meeting medical necessity criteria. The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available. Further, the insurer states that often after an extraction the bone can heal satisfactorily without the aid of biologic materials. The patient is appealing the decision. 

Upon review of the objective documentation which primarily consists of the panoramic radiographs, the patient exhibits missing #30 area. 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 documentation provided does not support, justify, or substantiate the requested treatment, particularly as the only objective documentation provided for review is the radiographic examination. There are no dental treatment records or periodontal records provided. 
 
Further, there is a body of literature to suggest that bone graft and ridge augmentation prior to implant placement are helpful procedures. However, although this treatment could be considered helpful it is an option, and not medically/dentally necessary. The surgical extraction site would heal within normal limits and assessment, after adequate healing, for bone graft and complementary procedures can be done prior to implant placement. Therefore, although this service could be done it is optional for this patient and the service would be deemed performed for the convenience of the patient. Although there is literature to support doctor's assertion that bone graft and ridge augmentation would be helpful in maintaining bone height, again this would be considered an optional procedure and not one that is considered medically necessary.

As noted, although bone grafting and ridge augmentation procedures could be considered helpful in preparing a surgical site for future implant placement this service is not a medically/dentally necessary procedure to be performed prior to implant placement. After healing of the extraction site, the bone could be assessed for residual height and assessment for any grafting at that time could be made. There is no absolute requirement that the bone graft and ridge augmentation be performed at the time of surgery.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for biologic materials, guided tissue regeneration, and bone graft performed on tooth number 30 is not substantiated.