Diagnosis: Periodontal disease

Treatment: D6010 implant placement, tooth 3, D6059 abutment supported porcelain fused to metal crown (high noble metal), tooth 3, D6057 custom abutment, tooth 3

The insurer denied coverage for D6010 implant placement, tooth 3, D6059 abutment supported porcelain fused to metal crown (high noble metal), tooth 3, D6057 custom abutment, tooth 3

The denial is upheld


This patient lost a number of teeth including 3, 18, 19, and 20. The patient had treatment planned for dental implants in all four areas. The insurance approved implants in 18-20 but did not mention 3. Since that time, tooth 3 has been denied due to a lack of information to make a definitive decision.

In an appeal letter it is noted the patient has moderate sleep apnea. The patient needs a dental appliance to treat his condition. He needs implants and the device has become a choking hazard.

Documentation provided for review does not support the requested treatment. There are no radiographs or comprehensive dental records to support the requested D6010 implant placement, tooth 3, D6059 abutment supported porcelain fused to metal crown (high noble metal), tooth 3, D6057 custom abutment, tooth 3. This documentation is necessary for proper evaluation of the patient's condition.

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 3, D6059 abutment supported porcelain fused to metal crown (high noble metal), tooth 3, D6057 custom abutment, tooth 3 is not substantiated.