Diagnosis: Edentulous space

Treatment: (D6010) implant placement, tooth #13; (D6057) custom abutment tooth #13; (D6058) abutment supported porcelain/ceramic crown tooth #13

The insurer has denied coverage for (D6010) implant placement, tooth #13; (D6057) custom abutment tooth #13; (D6058) abutment supported porcelain/ceramic crown tooth #13. The denial was upheld.

Based on review of the submitted documentation which includes copies of periapical radiograph, narrative letters of support and treatment notes in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for edentulous space in the area of the left maxilla #13 area. The treating doctor recommended endosteal implant to be placed at the site after discussion of treatment plans. The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only procedure or appropriate treatment and cite that an alternative appropriate therapy, as per the alternate benefits provision of the insurance contract, would initially be a removable partial denture which would restore form, function and esthetics but there are enough posterior contacts with remaining dentition to exclude this as well. Therefore the endosteal implants are considered not medically necessary, considered elective and therefore no benefit is available.

Upon review of the objective documentation which primarily consists of the periapical radiographs and treatment notes, it is evident tooth #13 was non maintainable as noted and restoration of the space was to be considered. He suggested an endosteal implant and associated services. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, as in this patient, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include a removable partial denture or a fixed three unit bridge as cited by the insurer. Therefore as partial dentures and fixed bridges remain standards of care in general dental practice, the alternate benefits provision of the insured's contract is valid and therefore the endosteal implants are considered elective and not medically necessary.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

Uphold denial of coverage for (D6010) implant placement, tooth #13; (D6057) custom abutment tooth #13; (D6058) abutment supported porcelain/ceramic crown tooth #13 as not medically necessary, as an appropriate alternative standard of care treatment would be a removable partial denture or a fixed bridge. Therefore, as other acceptable alternative treatments are appropriate this renders the endosteal implants not medically necessary.

Based on the above, the medical necessity for (D6010) implant placement, Tooth # 13; (D6057) custom abutment, Tooth 13; and (D6058) abutment supported porcelain/ceramic crown, Tooth # 13 is not substantiated. The insurer's denial is upheld.