Diagnosis: Dental Problems.
Treatment: Mandibular Partial Denture- Cast Framework with Resin Denture Bases for Lower Arch.
The insurer denied coverage for the Mandibular Partial Denture- Cast Framework with Resin Denture Bases for Lower Arch.

The denial is overturned.

This is a male patient who presented for evaluation and comprehensive dental care. Recommended treatment was for mandibular removable partial denture to restore function. The insurer has denied these services stating that there is adequate posterior occlusion and therefore, the services are deemed not medically necessary.

Upon review of the documentation, in particular the panoramic radiograph, the patient exhibits oligodontia in the maxilla and mandible. Review of the remaining dentition on radiograph indicates a level of moderate periodontal alveolar bone loss corresponding to periodontal disease but otherwise essentially stable alveolar bone height without severe periodontal disease. The teeth that would be supported for the removable partial denture are stable and would be adequate abutment teeth. This treatment is a standard of care in dental practice for this clinical circumstance. As this is a covered service and indicated for restoration of function and occlusal stability, the partial denture is considered medically/dentally necessary for this patient.

The recommendation is to overturn the denial and approve lower partial denture as partial dentures are designed for use in this clinical circumstance, are a covered service for this patient, are a standard of care in general dental practice, and would be an appropriate treatment to restore function and occlusal stability.

The mandibular partial denture- cast framework with resin denture bases for lower arch is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgement and in the best interest of the patient.

The medical necessity for the Mandibular Partial Denture- Cast Framework with Resin Denture Bases for Lower Arch is substantiated. The insurer's denial should be overturned.