Diagnosis: Oligodontia.
Treatment: D6010, implant placement for tooth 12, 13, 14, 15, 18, 19, 2, 20, 21, 3, 30, 31, 4; D4263 adding bone at one mouth site, tooth 10; D7140 removal of tooth or tooth root, tooth 29.

The insurer denied coverage for D6010, implant placement for tooth 12, 13, 14, 15, 18, 19, 2, 20, 21, 3, 30, 31, 4; D4263 adding bone at one mouth site, tooth 10; D7140 removal of tooth or tooth root, tooth 29. 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, a bone graft and extraction of a tooth. The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia, gag reflex and nausea.

Upon review of the objective documentation which primarily consists of a panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. Regarding 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 objectively support, justify, or substantiate the requested treatment. Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary. In regard to the extraction of #29, as per the submitted radiograph this tooth has been extracted and is no longer present.

An appropriate alternative standard of care treatment would be conventional removable dentures, and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. 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.

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

The insurer's denial of coverage for the D6010, implant placement for tooth 12, 13, 14, 15, 18, 19, 2, 20, 21, 3, 30, 31, 4; D4263 adding bone at one mouth site, tooth 10; D7140 removal of tooth or tooth root, tooth 29 is upheld. Medical Necessity is not substantiated.