Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia

Treatment: D5811 temporary lower denture, lower part of the mouth, D6010 implant placement, Tooth 19, D7951 sinus augmentation, upper left part of the mouth, D6010 implant placement, Tooth 3, D6010 implant placement, Tooth 4, D6010 implant placement, Tooth 6, D6010 implant placement, Tooth 9, D6010 implant placement, Tooth 11, D6010 implant placement, Tooth 13, D6010 implant placement, Tooth 14, D6010 implant placement, Tooth 30, D6010 implant placement, Tooth 28, D6010 implant placement, Tooth 26, D6010 implant placement, Tooth 23, D6010 implant placement, Tooth 21, D7951 sinus augmentation, upper right part of the mouth.

The insurer denied coverage for D5811, D6010 for Tooth 19, D7951, D6010 for Tooth 3, D6010 for Tooth 4, D6010 for Tooth 6, D6010 for Tooth 9, D6010 for Tooth 11, D6010 for Tooth 13, D6010 for Tooth 14, D6010 for Tooth 30, D6010 for Tooth 28, D6010 for Tooth 26, D6010 for Tooth 23, D6010 for Tooth 21, D7951 

The denial is upheld

This patient presented for dental evaluation and treatment, and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist recommended sinus lift augmentation surgeries and endosteal implants in areas as enumerated above. The dentist is requesting implants over removable partial dentures due to the patient's reported high/deep palate, difficulty with mastication with current unstable removable denture and difficulty speaking. The insurer has denied the services stating that 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 the endosteal implants and related services are considered not medically necessary, elective and therefore no benefit is available. 

Based on the panoramic and bitewing radiographs, the patient exhibits oligodontia in the maxilla and mandible and a metallic plate in the left mandible. Although implants are an acceptable treatment to restore edentulous spaces with or without sinus augmentation surgeries, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. The documentation provided does not support, justify, or substantiate the requested treatment. There are no dental treatment records or periodontal records provided. The documentation is inadequate, and as removable partial dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures, the sinus augmentation surgeries and endosteal implants are considered elective and not medically necessary.

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 D5811 temporary lower denture, lower part of the mouth, D6010 implant placement, Tooth 19, D7951 sinus augmentation, upper left part of the mouth, D6010 implant placement, Tooth 3, D6010 implant placement, Tooth 4, D6010 implant placement, Tooth 6, D6010 implant placement, Tooth 9, D6010 implant placement, Tooth 11, D6010 implant placement, Tooth 13, D6010 implant placement, Tooth 14, D6010 implant placement, Tooth 30, D6010 implant placement, Tooth 28, D6010 implant placement, Tooth 26, D6010 implant placement, Tooth 23, D6010 implant placement, Tooth 21, D7951 sinus augmentation, upper right part of the mouth is not substantiated.