Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia.
Treatment: Implant on teeth #7, #9, #14, #19, and #30 and bridge on tooth #8, implant crown on teeth #14, #19, #30, gum surgery (D4266, D4267, and D4263) on tooth #7.

The insurer denied coverage for implant on teeth #7, #9, #14, #19, and #30 and bridge on tooth #8, implant crown on teeth #14, #19, #30, gum surgery (D4266, D4267, and D4263) on tooth #7.  The denial is upheld.

Based on review of the submitted documentation, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentists/dental students have recommended an implant on teeth #7, #9, #14, #19 and #30 and a bridge on tooth #8, implant crown on teeth #14, #19, #30, and gum surgery (D4266, D4267 and D4263) on tooth #7. The dentist is requesting implants over removable partial dentures as per the patients directed request and due to the patient's self-reported difficulty with function and mastication with the current removable partial denture. The patient claims this has affected their mental health and nutritional status. 

Upon review of the objective documentation which primarily consists of the panoramic and bitewing radiographs, the patient exhibits oligodontia in the maxilla and mandible. In regard to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces with or without gingival surgeries, an 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 particularly as the only objective documentation provided for review is the radiographic examination. There are no dental treatment records or periodontal records provided. There is no objective information provided to corroborate the patient's self-reported claim to be unable to wear a removable prosthesis.

Per dental treatment note, it states "Treatment options include leave edentulous space empty, Removable Partial Denture (RPD) to restore edentulous areas, implant placements." A conventional removable partial denture was considered a viable option for this patient in the estimation of the treating doctors.

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

Based on the above, the insurer's denial is upheld. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. Medical necessity for the implant on teeth #7, #9, #14, #19, and #30, bridge on tooth #8, implant crown on teeth #14, #19, #30, and gum surgery (D4266, D4267, and D4263) on tooth #7 is not substantiated.