202302-159190
2023
Fidelis Care New York
Medicaid
Dental Problems
Dental/ Orthodontic Procedure
Medical necessity
Upheld
Case Summary
Diagnosis: Edentulous # (number) 18 and 29.
Treatment: D6010 implant placement, tooth 29; D6010 implant placement, tooth 18.
The insurer denied coverage for D6010 implant placement, tooth 29; D6010 implant placement, tooth 18. The denial is upheld.
Based on review of the submitted documentation which includes copy of panoramic radiograph, treatment/progress notes of varying dates with several doctors, narrative letter, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion status post orthodontic care regarding prosthetic rehabilitation for the mandible in the areas of edentulous # 18 and 29. The dentists/surgeons recommended endosteal implants in areas as enumerated above. These clinicians are recommending endosteal implants for masticatory efficiency. 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. 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. The insurer suggests that either removable partial dentures or conventional fixed bridge placement are covered and allowed alternative therapies. The patient is appealing the decision.
Upon review of the objective documentation which primarily consists of the panoramic radiograph and treatment notes, the patient exhibits oligodontia and is missing #18 and 29. 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 or a fixed denture prosthesis/bridge. In this case the removable partial denture in the mandible 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 or a fixed bridge remain standards of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures, the endosteal implants are considered elective and not medically necessary.
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.
The medical necessity for D6010 implant placement, tooth 29; D6010 implant placement, tooth 18 is not substantiated.