Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems/other.
Treatment: Dental Procedures.
The insurer denied 10-unit bridge involving teeth #s 20, 21, 22, 23, 24, 25, 26, 27, 28 and 29.
The denial is upheld in whole. 

The patient who presents to the dental office for evaluation and treatment of teeth #20, 21, 22, 23, 24, 25, 26, 27, 28 and 29.
No, the requested health service/treatment of 10-unit bridge involving teeth #'s 20,21,22,23,24,25,26,27,28, and 29 is not medically necessary. The patient suffered from partial edentulism including missing both mandibular canines. From the provided documentation, there was no evidence of decay on abutment teeth #20, 21, 28, and 29.
The letter from the dental provider  states that the old bridge from #22-27 resulted in teeth #22 and 27 having greater than grade 2 mobility. The letter continues to state that there will be double abutments bilaterally due to the expansiveness of the prosthesis. Further, the dental provider stated that this design was also a result of the needs of the patient's gingival condition. The letter continues to state that the design is to ensure reasonable success. In regard to this information, the previous shorter span bridge resulted in class 2 mobility on the abutment teeth (#22 and 27), teeth which have the longest teeth in the mandible. This is an indication that making longer spacing bridges using teeth with shorter roots will not be indicated as the load will be exponentially worse. The use of double abutments has been shown to result in greater stress and load on the teeth immediately adjacent to the edentulous area with little help from the distal most abutment tooth, explaining why these types of prosthesis have higher failure rates. In regards to the rationale that the patient has a gingival condition, although the condition is not diagnosed nor explained, if the patient does suffer from periodontal disease of any type, there is even less rationale for a longer spacing prosthesis as the immediate abutments will suffer from a greater lack of retention within the periodontium due to disease and will result in earlier failure; so the periodontal condition as stated in the letter makes things worse for the designed prosthesis.  
  All of the information provided by the dental provider the letter gives indication to avoid a long span prosthesis and instead design a replacement for teeth using either a removable partial denture or an implant supported prosthesis. The standard of care for replacement of missing teeth with this span of six missing teeth including the mandibular canines is not for a long spanning 10-unit denture with double abutments on periodontally involved teeth with history of mobility on the shorter span bridge using canines. The standard of care here would be either to replace the missing support and provide canine guidance and replace the missing teeth with implants in sites #22 and 27 and implant retained prosthesis from 23-26 with implants as abutments in sites 23 and 26. The other standard of care would be to replace the missing teeth with a removable partial denture. 
There is no support for the treatment rendered hence the treatment is not medically necessary.