Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Dental Problems
Treatment: Bone Grafting
The insurer denied bone grafting of teeth number (#) 11 and 13. The health plan's determination is overturned.

The patient is a male who presents for evaluation and treatment of teeth #11 and 13. Provided for review are previous letters of appeal and denial, full mouth radiographic images, one page of American Dental Association (ADA) claim forms, a narrative from the provider, and clinical notes. In question is the medical necessity of the treatment of bone graft for site of teeth #11 and 13 (D7953).

The Bone Grafting in the Site of Teeth #11 and 13 is medically necessary for this patient.

Based on the provided documentation, there is a need to preserve the ridge dimensions after the teeth were extracted. If the ridge dimensions are not preserved, a dental implant would not be able to be placed at a future date without more significant grafting.
The stated reason for grafting for both teeth #11 and 13 was for preservation of the ridge for dental implants at the time of extraction. This qualifies as medically necessary as it preserves the ridge dimensions to allow for future implant placement. Dental implants require bone to surround the implant and offer a base for osseointegration. Without adequate bone dimension, the implant cannot be placed. Grafting at the site of extraction prevents soft tissue ingrowth and loss of bone dimension as a result. Hence, the requested treatment is required for both #11 and 13 as it is medically necessary.