Appeal type: Medical necessity
Decision: Overturned

Diagnosis: single missing teeth, including 19

Treatment abutment supported crown (D6059).

The insurer denied coverage for abutment supported crown (D6059).

The denial is overturned.

This is the case of an adult male who has been under the care of his dentist for his dental care. The patient has suffered from a few single missing teeth, including 19, for which the patient had an implant placed recently. He is also preparing for the abutment and crown.

"Placement of implant requires an interdisciplinary approach wherein a team of dental implant specialists including oral surgeon, prosthodontist, periodontist, and oral radiologist participate in the planning, execution, and maintenance of the implants to ensure the best possible outcome. Once the implants have been placed in the edentulous region routine maintenance, recall evaluations and radiographs are necessary to ensure the long life of these restorations, and this necessitates the team of dental implant specialists to be well versed with the implant maintenance procedures as well, as an implant failure would result in a debate, which would give the profession no credit." (Gulati, M. et al.)

"The goal of modern dentistry is to restore the patient to normal profile, function, comfort, esthetics, speech, and health regardless of the atrophy, disease, or injury of the stomatognathic system.

People are living longer on average. This fact, combined with an existing population of patients with minor and major dental problems, guarantees the future of implant dentistry for several generations of dentists. Dental implants are increasingly used to replace single teeth, especially in the posterior regions of the mouth. Rather than removing sound tooth structure and crowning two or more teeth, increasing the risk of decay, endodontic therapy, and splinting teeth together with pontics, which may have the potential to decrease oral hygiene ability and increase plaque retention, a dental implant may replace the single tooth.

Organized dentistry has finally accepted implant dentistry. The current trend to expand the use of implant dentistry will continue until every restorative practice uses this modality for abutment support of both fixed and removable prostheses on a regular basis as the primary option for all tooth replacements." (Gupta, R. et al.)

"Tooth loss is a very common problem; therefore, the use of dental implants is also a common practice. Although research on dental implant designs, materials and techniques has increased in the past few years and is expected to expand in the future, there is still a lot of work involved in the use of better biomaterials, implant design, surface modification and functionalization of surfaces to improve the long-term outcomes of the treatment." (Gaviria, L. et al.)

An abutment supported crown (D6059) is considered medically necessary for this patient. The patient already has the implant placed. It does need to be restored. For this reason, and to get the patient back to normal function, this implant needs to be restored with an abutment and crown.

The insurer's denial of coverage for abutment supported crown (D6059) is overturned. Medical necessity is substantiated.