Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems (evaluation and management of non-maintainable tooth site #14).

Treatment: Bone graft and guided tissue regeneration on tooth #14.

The insurer denied coverage for the bone graft and guided tissue regeneration on tooth #14.

The denial is upheld. 

This is a female patient who presented for evaluation and management of non-maintainable tooth site #14.  Based on the clinical and radiographic findings, the dentist recommended bone graft and guided tissue regeneration.  These services were recommended to prepare tooth site #14 for future implant placement.  

Based on the clinical and radiographic information provided for review, the alveolar bone height is acceptable on submitted radiographs and presumably this same level of bone was present at the time of extraction.  At this point, treatment options might include extraction with bone graft and guided tissue regeneration, as recommended and performed by the treating dentist.  There is a body of literature to suggest that bone graft and ridge augmentation prior to implant placement are helpful procedures in that vein.  However, although this treatment could be considered helpful it is an option and not medically/dentally necessary. The surgical extraction site would heal within normal limits, and assessment after adequate healing, for bone graft procedures, can be done prior to implant placement.  Therefore although this service could be done, it is optional for this patient.  Therefore the service would be deemed performed for the convenience of the patient.  Although there is literature to support doctors' assertion that bone graft and ridge augmentation would be helpful in maintaining bone height, this would be considered an optional procedure and not one that is considered medically necessary.  Furthermore, implants and related services are explicitly non-covered services under this specific plan.

As per review of the medical record and literature, the coverage for the bone graft and guided tissue regeneration on tooth #14 is not considered medically necessary for this patient. The surgical extraction site is expected to heal normally and assessment for graft and ridge augmentation could be made at a later date prior to implant placement.  Therefore, the dental procedures performed on this patient are not medically necessary.  As noted above, although bone grafting and ridge augmentation procedures could be considered helpful in preparing a surgical site for future implant placement, this service is not a medically/dentally necessary procedure to be performed prior to implant placement.  After healing of the extraction site the bone could be assessed for residual height and assessment for any grafting at that time could be made.  There is no absolute requirement that the bone graft and ridge augmentation be performed at the time of surgery.

The bone graft and guided tissue regeneration on tooth #14 is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgement and in the best interest of the patient.

The carrier's denial of coverage for the bone graft and guided tissue regeneration on tooth #14 should be upheld.  The medical necessity is not substantiated.