Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis
Treatment: Computed Tomography scans
The insurer denied coverage for Computed Tomography scans
The denial is upheld 

The patient is an adult who has a medical diagnosis of osteoporosis. Per the dental provider, before the dental implants can be placed, the health of the bone needs to be checked to see if it can hold a dental implant. The computed tomography (CT) scan is needed to check the health of the bone near nerves and the sinuses to place the dental implants. The treating provider is requesting plan approval for a CT scan, which is under medical necessity review.
 
Based on studies, the major determinants affecting implant failure are smoking and history of radiotherapy. There is no explanation why radiographs alone are insufficient for the patient. There is no documentation of skeletal fractures, or mandibular fractures or deformities seen in the patient that need to be addressed prior to dental implant placement. 

"A total of 51 studies were identified in this meta-analysis, with more than 40,000 dental implants placed under risk-threatening conditions. The pooled relative risks (RRs) showed a direct association between smoking (n (number) = 33; RR = 1.92; 95% CI (confidence interval), 1.67-2.21) and radiotherapy (n = 16; RR = 2.28; 95% CI, 1.49-3.51) and the risk of dental implant failure, whereas no inverse impact of diabetes (n = 5; RR = 0.90; 95% CI, 0.62-1.32) on the risk of dental implant failure was found. The influence of osteoporosis on the risk of dental implant failure was direct but not significant (n = 4; RR = 1.09; 95% CI, 0.79-1.52). Smoking and radiotherapy were associated with an increased risk of dental implant failure. The relationship between diabetes and osteoporosis and the risk of implant failure warrants further study" (Chen, H., Liu, N., Xu, X., Qu, X., Lu, E. 2013). 

"Comprehensive and accurate radiographic assessment provides all necessary surgical and prosthetic information required for the success of the venture. Various types of imaging modalities are used for dental implant imaging: Periapical radiography, Panoramic radiography, Occlusal radiography, Cephalometric radiography, Computed tomography (medical CT and cone beam CT), Interactive CT. " (Gupta, R., Gupta, N., Weber, DDS K.K., 2022). 

"Regarding peri-implantitis, the diagnosis and severity of the disease should be evaluated primarily based on clinical parameters and on radiological findings based on periapical radiographs (two dimensional). The use of cone beam computed tomography scans in clinical research might not yield any evident beneficial effect for the patient included. For preoperative cross-sectional imaging, data are still not available which demonstrate that cone beam computed tomography results in fewer intraoperative complications such as nerve damage or bleeding incidents, or that implants inserted using preoperative cone beam computed tomography data sets for planning purposes will exhibit higher survival or success rates." (Bornstein, M. M., 2017).
  
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 Computed Tomography scans is not substantiated.