Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Issues
Treatment: CT scan, implant placement, custom abutment and abutment supported porcelain fused to metal crown (predominantly base metal) for tooth number (#)30
The insurer denied the CT scan, implant placement, custom abutment and abutment supported porcelain fused to metal crown (predominantly base metal) for tooth #30.
The health plan's determination is overturned.

The patient is a female who is missing tooth number (#)30. The provider obtained a computed tomography (CT) and placed an implant in this area. This will be restored with an abutment and a crown. This was denied as a partial denture is an option.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient. 

The requested health service/treatment of a CT scan, implant placement, custom abutment and abutment supported porcelain fused to metal crown (predominantly base metal) for tooth #30 medically necessary.  

A Position Paper Subcommittee of the American Academy of Oral and Maxillofacial Radiology (AAOMR) reviewed the literature since the original position statement on selection criteria for radiology in dental implantology, published in 2000. All current planar modalities, including intraoral, panoramic, and cephalometric, as well as cone beam computed tomography (CBCT) are discussed, along with radiation dosimetry and anatomy considerations. We provide research-based, consensus-derived clinical guidance for practitioners on the appropriate use of specific imaging modalities in dental implant treatment planning. Specifically, the AAOMR recommends that cross-sectional imaging be used for the assessment of all dental implant sites and that CBCT is the imaging method of choice for gaining this information.

The options to restore function in this case are a bridge or an implant. An implant is the best choice. A partial denture has been shown to lead to the loss of adjacent teeth and have less chewing efficiency than implants. Implants are the standard of care and much more efficient than a partial. They are the closest thing to natural teeth, preserve the bone and are not susceptible to caries. 
A bridge is considered radical treatment as adjacent tooth structure must be drastically reduced in this process. The bridge has been regarded as the standard of care for some time in the replacement of single and multiple missing teeth. However, to obtain optimal functional and aesthetic results for full-veneer bridges, a significant reduction in the amount of tooth structure is necessary occasionally predisposing to endodontic, periodontal, and structural complications. The abutment teeth often become carious and have an increased rate of needing a root canal procedure. If one of the abutment teeth are lost a longer span bridge would be required. The implant procedure is more conservative and has a better prognosis. Implants have a high rate of success, do not require procedures on adjacent teeth and are not susceptible to caries. The implant procedure is not complete until it has been restored. The abutments and crowns are needed to complete the restoration and are medically necessary.

The health plan's determination of medical necessity is overturned in whole.