Diagnosis: Failing denture.
Treatment: Bone Replacement Graft For Ridge Preservation,
per site (D7953) Guided Tissue Regeneration, Natural Teeth-Resorbable Barrier, per site (D4266).

The insurer denied: Bone Replacement Graft For Ridge Preservation, per site (D7953) Guided Tissue Regeneration, Natural Teeth-Resorbable Barrier, per site (D4266).

The denial is overturned.

The patient is an elderly male who had a failing lower partial denture secondary to non-restorable teeth. The teeth were removed, the areas grafted, and osseointegrated implants placed to support an overdenture. The grafting and membranes placed over the teeth was denied coverage by the health plan, because it did not meet plan guidelines. Specifically, the denial was because "only one regenerative procedure per site (or tooth) is allowed." The denial is being appealed.

The requested health service was medically necessary.

The placement of the graft was necessary to maintain both height and volume of the proposed implant sites. The barrier membrane was used for the purpose of covering and maintaining the graft material. The membrane was not used as a regenerative material - it was a resorbable membrane that prevented the graft material from being washed away. The standard of care and literature require that something be placed over the graft material - this can be a soft tissue graft or a resorbable or non-resorbable material - that will protect the graft. If not done, the graft material would be gone in a matter of days.

The description for code D7953 clearly states that if a membrane is used it should be reported separately - this is what was done.

Therefore, given the above, the requested health service was medically necessary.