Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Poor dentition
Treatment: Crown on tooth #9, implant on teeth #7, #8, gum surgery on teeth #8, implant on teeth #14, #19, #30, and implant crown on teeth #7, #8, #14, #19, and #30
The insurer denied coverage for crown on tooth #9, implant on teeth #7, #8, gum surgery on teeth #8, implant on teeth #14, #19, #30, and implant crown on teeth #7, #8, #14, #19, and #30.
The denial is upheld.
 
Upon review of the objective documentation which primarily consists of the panoramic and bitewing radiographs, the patient exhibits oligodontia in the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces with or without gingival surgeries, 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. There is no objective information provided to corroborate the patients self-reported claim that he is unable to wear a removable prosthesis.

Further, as per dental treatment note, it states "Treatment (Tx) plan .... Options included:
Leave edentulous space empty, removable partial denture (RPD) to restore edentulous areas, implant placements." So, a conventional removable partial denture was considered a viable option for this patient in the estimation of the treating doctors.

Further, on examination of the notes from the social work visits there is no mention at any of these visits that his inability to wear a denture has impacted his mental state. In only one note is dental care mentioned, and in that note, it is to discuss his frustration with a prior dental office who he felt did not treat him appropriately and his difficulty managing his emotions. It did not focus on the actual dental care delivered. Therefore, as the documentation is inadequate, and as removable partial dentures remain a standard of care in general dental practice, and further the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty and does not meet New York State (NYS) criteria for approval, the gum surgery, endosteal implants and crowns are considered elective and not medically necessary.

Uphold denial of coverage for gingival surgery, endosteal implants and crowns as not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable denture and the medical documentation provided does not substantiate a limitation that would preclude the patient using a removable partial denture. 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 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 crown on tooth #9, implant on teeth #7, #8, gum surgery on teeth #8, implant on teeth #14, #19, #30, and implant crown on teeth #7, #8, #14, #19, and #30 is not substantiated.