Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Edentulous maxilla and Oligodontia in the mandible

Treatment coverage for endosteal implants for (#) tooth number 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 28, 29, 30, and 31

The insurer denied coverage for coverage for endosteal implants for (#) tooth number 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 28, 29, 30, and 31

The denial is upheld

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in #2, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14, #15, #18, #19, #20, #21, #28, #29, #30 and #31. The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. The insurer has denied the services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants. The insurer state that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits and edentulous maxilla and oligodontia in the mandible. As regards to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, 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. Therefore, as removable dentures (full and partial removable) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.

Endosteal implants #2, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14, #15, #18,
#19, #20, #21, #28, #29, #30 and #31 is not considered medically necessary for this patient.

Uphold denial of coverage for dental implants as not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable full and partial dentures. 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,

The insurer's denial of coverage for endosteal implants for #2, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14, #15, #18, #19, #20, #21, #28, #29, #30 and #31 is upheld. Medical Necessity is not substantiated.