Issued and entered December 19, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On August 13, 2002 the Petitioner, XXXXXXXXX, filed a request for external review with the Commissioner of Financial and Insurance Services under the Patient’s Right to Independent Review Act, MCL 550.1901 to MCL 550.1929. After a review of the material submitted, the Commissioner accepted the request. The issue involved is both contractual and medical in nature. The Commissioner therefore assigned it to an independent review organization (“IRO”) on August 20, 2002. On September 3, 2002 the IRO provided its recommendation to the Commissioner.

II
FACTUAL BACKGROUND

The Petitioner received dental implants on XXXXXXXXXXXX. Charges for these services were $2,814.00. Blue Cross and Blue Shield of Michigan (“BCBSM”) failed to pay for the Petitioner’s implants asserting that the claim did not meet BCBSM’s criteria for payment.

III
ISSUE

Are the Petitioner’s dental implants a covered benefit under his certificate of coverage?

IV
ANALYSIS

Petitioner’s Position

The Petitioner suffered from ill-fitting dentures. His dentist recommended dental implants to alleviate the problem. Petitioner asserts that his x-rays showed that he was within BCBSM’s guidelines with respect to the size of his jaw line for dental implants. He also indicated he was in a situation where he was unable to chew without serious problems. Therefore, he believes his dental implants are a covered benefit under his certificate and BCBSM is required to pay for them.

BCBSM’s Position

BCBSM argues that its coverage is only available if dental surgery is treatment for an accidental injury.

Independent Review Organization (IRO) Recommendation

The IRO concluded that the dental implants the Petitioner received were medically necessary to treat his condition and that there is no evidence that the Petitioner’s teeth were lost due to trauma from an accident.

Commissioner’s Review

Petitioner is enrolled through XXXXXXXXXXXXXXXX, an experienced rated group. The Community Blue Group Benefit Certificate governs the coverage. Under this certificate, dental services are covered under very limited circumstances. In the Petitioner’s BCBSM certificate, coverage for dental services is described in the section “Coverage for Other Health Care Services” which states:

Dental Care and Dental Appliances

We pay our approved amount for treatment of accidental injuries sustained after the effective date of this certificate.
We do not pay for medical or dental services performed for irreversible treatment of jaw joint disorders, except for:
· surgery on the jaw joint
· diagnostic x-rays
· arthrocentesis

In the case at hand, the dental care provided the Petitioner was dental implants. They were not the result of an accidental injury and they did not involve the jaw joint.

It is not disputed that the Petitioner required dental implants. However, there is no provision in the certificate that makes dental implant services a covered benefit, even if they are medically necessary. Therefore, the Commissioner finds the dental services the Petitioner received on XXXXXXXXXX are not a covered benefit under the BCBSM certificate.

V
ORDER

The August 1, 2002 final adverse determination of BCBSM is upheld. BCBSM is not required to pay for the dental implants provided the Petitioner on XXXXXXXXX.

This is a final decision of an administrative agency. Under MCL 550.1915, MCL 600.631, MCR 7.101 and MCR 7.104, any person aggrieved by this order may seek judicial review no later than sixty days from the date of this order in the circuit court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.