Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bulbous bone on both the mandible and maxilla; large maxillary tori 

Treatment: D0367 (Cone Beam CT scan of Both Jaws); D6010 (Implant Placement, Tooth 4, Tooth 6, Tooth 11, Tooth 13, Tooth 22, Tooth 27 and Tooth 29); D6052 (Attachment Abutment, Lower Arch, Upper Arch and Tooth 20); D6104 (Bone Graft at Time of Implant Placement, Tooth 4, Tooth 6, Tooth 11, Tooth 13, Tooth 22, Tooth 27 and Tooth 29); D6110 (Implant Supported Upper Denture, Upper Arch) and D6111 (Implant Supported Lower Denture, Lower Arch)

The insurer denied coverage for D0367 (Cone Beam CT scan of Both Jaws); D6010 (Implant Placement, Tooth 4, Tooth 6, Tooth 11, Tooth 13, Tooth 22, Tooth 27 and Tooth 29); D6052 (Attachment Abutment, Lower Arch, Upper Arch and Tooth 20); D6104 (Bone Graft at Time of Implant Placement, Tooth 4, Tooth 6, Tooth 11, Tooth 13, Tooth 22, Tooth 27 and Tooth 29); D6110 (Implant Supported Upper Denture, Upper Arch) and D6111 (Implant Supported Lower Denture, Lower Arch). The denial was upheld.

This patient is a male who presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible.  The treating doctor deemed the remaining maxillary and mandibular dentition hopeless and has recommended extractions of all remaining maxillary and mandibular teeth and subsequent endosteal implants to be placed in the #4, 6, 11, 13, 22, 27, and 29 sites, associated implant related procedures as enumerated above and implant retained maxillary and mandibular dentures.  He states a gag reflex as a rationale for implant retained prostheses. The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only appropriate treatment and cite that an alternative appropriate therapy is complete removable dentures which would restore form, function and esthetics.

Upon review of the objective documentation which primarily consists of the panoramic radiograph, and intraoral images, it is evident that the remaining maxillary and mandibular dentition is not salvageable and extraction of remaining dentition is recommended as noted.  He suggested endosteal implants and associated services.  As regards 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 conventional removable dentures as cited by the insurer.  Therefore as removable dentures remain a standard of care in general dental practice, the endosteal implants are considered elective and not medically necessary.  Further, although it is suggested that the underlying medical issue of diabetes and gag reflex would compromise function there is no specific objective documentation to support or substantiate this claim, nor is there objective findings that document the patient's inability to wear removable prostheses.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The requested services are not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable dentures.  There are other acceptable alternative treatments. 

Based on the above, the medical necessity for dental codes D0367 (Cone Beam CT scan of Both Jaws); D6010 (Implant Placement, Tooth 4, Tooth 6, Tooth 11, Tooth 13, Tooth 22, Tooth 27 and Tooth 29); D6052 (Attachment Abutment, Lower Arch, Upper Arch and Tooth 20); D6104 (Bone Graft at Time of Implant Placement, Tooth 4, Tooth 6, Tooth 11, Tooth 13, Tooth 22, Tooth 27 and Tooth 29); D6110 (Implant Supported Upper Denture, Upper Arch) and D6111 (Implant Supported Lower Denture, Lower Arch) is not substantiated.  The insurer's denial is upheld.