Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth loss
Treatment: Implants (D6010) for teeth numbers 4, 5, and 29 
The insurer denied coverage for implants (D6010) for teeth numbers 4, 5, and 29.
The denial is overturned.

The medical records show that the patient fractured tooth number (#) five (5), which was surgically removed, and an implant was placed. Implants were also placed for missing teeth # four (4) and 29. The request for coverage of the implantations was denied stating there were other options. The provider is appealing the denial.

A letter from the insurer, documents that the coverage was denied for implants as this does "not appear to be the only method of tooth replacement available." The provider believes that patient would benefit from the "Implant placement with implant supported overdentures or fixed bridge (that) would provide the patient with more support and stability than a traditional denture or bridge. The patient has more efficiency of chewing food and also speaking more clearly."

The treatment plan was appropriate to restore the dentition with a fixed option. The placement of these implants will allow for better function than some type of removable prosthesis. In the best interest of the patient, the implants are appropriate.      

Implants (D6010) for teeth #s 4, 5, and 29 are considered medically necessary for this patient. 

The replacement of the teeth, in question, will allow for greater function. Removable prostheses are difficult to use and provide less efficiency of mastication and speech.

"ISRPDs (implant supported removable partial dentures) significantly improved quality of life and patient satisfaction. Some mechanical and biological complications have been associated with ISRPD treatment, requiring regular monitoring of patients to avoid the occurrence of these complications." (Bandiaky, O. N., et al., 2022)

"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. 2014)

"Many options exist to replace missing teeth, but dental implants have become one of the most used biomaterial to replace one (or more) missing tooth over the last decades." (Guillaume B. 2016)

"A dental implant is one of the treatments to replace missing teeth. Their use in the treatment of complete and partial edentulism has become an integral treatment modality in dentistry. Dental implants have a number of advantages over conventional fixed partial denture:

A high success rate (above 97% for 10 years)

A decreased risk of caries and endodontic problems of adjacent teeth
Improved maintenance of bone in edentulous site
Decreased sensitivity of adjacent teeth

A dental implant is a structure made of alloplastic materials implanted into the oral tissues beneath the mucosa and/or periosteum and/or within or through the bone to provide retention and support for a fixed or removable dental prosthesis." (Gupta, R., Gupta, N., & Weber, DDS, K. K. 2022)                                                        

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for implants (D6010) for teeth #4, #5, and #29 is substantiated.