Diagnosis: Oligodontia.
Treatment: D6010 implant placement for tooth 6, 8, and 9.

The insurer denied coverage for D6010 implant placement for tooth 6, 8, and 9.

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. 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, difficulty with mastication and nausea. The insurer has denied the aforementioned 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.

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in the maxilla and mandible. As regards to 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.

In this case, the removable partial denture in the maxilla would be entirely tooth borne, the most stable and retentive of all removable appliances. Further the documentation provided does not support, justify, or substantiate the requested treatment. Therefore, as removable partial dentures 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.

An appropriate alternative standard of care treatment would be conventional removable denture and the medical documentation provided does not substantiate a limitation that would preclude the patient using a removable partial denture. 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 D6010 implant placement for tooth 6, 8, and 9 is upheld. Medical Necessity is not substantiated.