Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing Tooth

Treatment: Upper partial denture

The insurer denied coverage for upper partial denture

The denial is upheld. 

This is a patient that had a treatment plan for partial dentures. The insurance company denied the request based on their criteria. The patient appears to have had a tooth removed at some point around the deliberations. This is an appeal for upper partial dentures, which is under review.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.      

The upper partial denture is not considered medically necessary for this patient. 

From the records and notes available for review, there doesn't appear to be a need for upper partial dentures. The patient has 12 natural teeth in biting contact. The program's Dental Guidelines require the patients to have less than eight points of biting contact. 

Therefore, the request for the upper partial denture is not medically necessary and is denied.

"For a patient with severe hypodontia, the teeth most likely to develop are the upper central incisors, upper and lower canines and first molar teeth. Patients with these few teeth may be managed with removable partial or complete overdentures but often benefit from some initial orthodontic treatment. The aim of this is to address a frequent patient complaint of a gap between their upper teeth. By aligning the upper central incisor teeth together and coincident with the facial midline, other visible gaps can be filled with the partial denture or overdenture. This approach improves the young patient's self-confidence related to their dental appearance, introduces them to the benefits of dental treatment, and assists with the longer-term tooth positioning and treatment planning processes. However, some young patients who wear dentures may express some level of body image dissatisfaction and psychological morbidity" (Pace-Balzan A., et al 2023).

"The Chulalongkorn University Masticatory Index (CUMI) may assist in denture quality evaluation without requiring a dental professional or trained personnel to evaluate denture retention and stability. In this study, the fixed partial denture (FPD) group served as a positive control because they showed the least frequent eating impact, and the highest masticatory performance and CUMI score. Approximately 79% (percent) of them could easily chew all food items or get a full CUMI score. Difficulty or inability to chew food items in grade I or II indicates increased severity of tooth loss and denture quality compared with the inability to chew those in grade III-V. Difficulty or inability in chewing food items in grade III-V, and those in grade III and IV was more likely to be reported by patients with an unacceptable removable partial denture (RPD) quality and unacceptable complete denture (CD) quality, respectively. It was noted that most CD wearers had difficulty or were unable to chew grade V food items and grains or seeds regardless of denture quality. Therefore, to maximize the masticatory ability of CD wearers, mandibular two-implant overdentures should be recommended as the first-choice standard of care for edentulous patients" (Limpuangthip N., et al 2022).

"For a short term period of 1 year, periodontal and mobility parameters have no significant impact on the abutment and non-abutment teeth of acrylic removable partial denture (ARPD) and metallic removable partial denture (MRPD) users. Moreover, biochemical markers (c-reactive protein [CRP] and alkaline phosphatase [ALP]) for periodontal inflammation exhibited no significant difference in both types of dentures" (Bukleta MS., et al 2023). 

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 an upper partial denture is not substantiated.