Diagnosis: Dental Disorder
Treatment: Partial lower denture, lower right part of mouth
The insurer denied the Partial lower denture, lower right part of mouth.
The determination is overturned.


The patient presented for the treatment of a mandibular partial denture 5214 for the lower right part of the mouth. Provided for review are a letter from the patient, letters of appeal and denial, radiographic images and a single page of American Dental Association (ADA) claim forms. According to the health plan, to qualify for partial dentures, there must be less than eight back teeth that touch in order to qualify for a partial denture. At issue is the medical necessity of partial lower denture, lower right part of mouth.

The requested health service/treatment of partial lower denture, lower right part of mouth is medically necessary for this patient.
The standard of care for patients with a diagnosis of partial edentulism is to replace the missing teeth, either with a partial/full denture, or implant/tooth retained prosthesis. The requested treatment is considered medically necessary based on the diagnosis itself and a residual dentition that can provide support stability and retention which is the case for this patient. As the patient is missing teeth, they do require replacement, this is the entire basis for the field of removable prosthodontics and removable partial dentures. Hence, the treatment of lower partial denture 5214 is medically necessary for this patient.