Diagnosis: Dental decay, missing teeth.
Treatment:Implant Placement (D6010) Teeth #s 3, 5, 6, 8, 9, 11, 12, 14, 22, 25, 27, and 30.
The insurer denied the Implant Placement (D6010) Teeth #s 3, 5, 6, 8, 9, 11, 12, 14, 22, 25, 27, and 30.
The denial is upheld.

The patient is a male. This patient suffered a baseball bat to the jaws early in life causing jaw fractures and loss of teeth. At this time, the patient is under the care of a dentist, oral maxillofacial surgeon (OMS), and physician. The patient is being treated for anxiety and depression. The doctor mentions that the patient has speech and nutrition issues. The patient has been diagnosed with dental decay with many decayed, missing, non-restorable teeth. The records mention the patient has a gag reflex. The dentition has been diagnosed as failing and a recommended treatment plan was proposed to include removal of all teeth, bilateral sinus lifts with grafts, and eight maxillary and six mandibular implant placement.

No, the proposed treatment is not medically necessary.
The records do not support medical necessity for the proposed treatment. There is no evidence to support the attempt to salvage the current dentition. There is no evidence of any attempt at removal prostheses. There is no evidence provided that this patient's current dentition is nonrestorable.

Yes, the health plan acted reasonably in this decision.
The decision was based on all the information provided for review from the health plan, dentist, oral maxillofacial surgeon (OMS), physician, and legal services.