Diagnosis: Oligodontia

Treatment: Implant placement (tooth numbers 2, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 3, 30, 31, 4, 5, 6, 7, 8 and 9) (code D6010 - surgical placement of implant body; endosteal implant)

The insurer denied coverage for implant placement (tooth numbers 2, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 3, 30, 31, 4, 5, 6, 7, 8 and 9) (code D6010 - surgical placement of implant body; endosteal implant).

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas as enumerated above. The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. The insurer has denied the services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants. The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available.

Upon review of the objective documentation which primarily consists of panoramic radiograph, the patient exhibits an edentulous maxilla and oligodontia in the mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, 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. Therefore, as removable dentures (full and partial removable) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

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

Implant placement teeth: #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13
#14, #15, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and 31 (code D6010 - surgical placement of implant body; endosteal implant) is not considered medically necessary for this patient.

The insurer's denial of coverage for implant placement (tooth numbers 2, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 3, 30, 31, 4, 5, 6, 7, 8 and 9) (code D6010 - surgical placement of implant body; endosteal implant) is upheld. Medical Necessity is not substantiated.