Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stable reproducible molar to molar occlusion -left side 

Treatment: D6010 implant placement, Tooth 15; D6057 custom abutment, Tooth 15; D6058 abutment supported porcelain/ceramic crown, Tooth 15; and D6104 Bone graft at time of implant placement, Tooth 15

The insurer denied coverage for D6010 implant placement, Tooth 15; D6057 custom abutment, Tooth 15; D6058 abutment supported porcelain/ceramic crown, Tooth 15; and D6104 Bone graft at time of implant placement, Tooth 15. The denial upheld.

This patient is a female who presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the #15 area. The provider deemed #15 hopeless and has recommended extraction and subsequent graft, endosteal implant and associated services. The insurer has denied the aforementioned services stating that in their estimation, endosteal implants are not the only appropriate treatment.

Upon review of the objective documentation, which primarily consists of the panoramic and periapical radiographs, it is unclear whether #15 is not salvageable and extraction is recommended. Regardless, the provider suggested endosteal implant and associated services at the site. As regards to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces as in this patient, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include a conventional removable denture as suggested by the insurer vs no additional treatment as the patient has a stable reproducible molar to molar occlusion on the left side. Further, the documentation provided does not support, justify or substantiate the requested treatment. Therefore, as removable dentures remain a standard of care in general dental practice, the endosteal implants are considered elective and not medically necessary. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  D6010 implant placement tooth #15; D6057 custom abutment tooth 15; D6058 abutment supported porcelain/ceramic crown tooth 15; D6104 bone graft at time of implant placement, tooth #15 is not considered medically necessary for this patient. 

Uphold denial of coverage for D6010 implant placement tooth #15; D6057 custom abutment tooth 15; D6058 abutment supported porcelain/ceramic crown tooth 15; D6104 bone graft at time of implant placement, tooth #15 as not medically necessary, as an appropriate alternative standard of care treatment would be a conventional removable denture or no additional treatment.  Therefore, as other acceptable alternative treatments are appropriate and the documentation provided does not support the recommended treatment, this renders the endosteal implants and associated services not medically necessary.

Based on the above, the medical necessity for D6010 implant placement, Tooth 15; D6057 custom abutment, Tooth 15; D6058 abutment supported porcelain/ceramic crown, Tooth 15; and D6104 Bone graft at time of implant placement, Tooth 15 is not substantiated.  The insurer's denial is upheld.