More and more dentists are seeking the option to bill dental implants and, in particular, overdentures. It is important to establish medical necessity for these procedures so, if a covered benefit, you will have no issues seeking reimbursement for your patient.
There are several questions that can be asked to determine medical necessity and help gather the necessary background to choose the most appropriate diagnosis codes:
1. Is the condition due to a traumatic injury?
2. Is there a current or previous infection that resulted in the loss of teeth?
3. Were the teeth lost as a result of other health treatments such as chemotherapy or radiation?
4. Is the patient suffering from loss of function?
5. Does the patient have other health conditions that are exacerbated by the lack of dentition? (Examples could be GERD, diabetes, ulcers or other digestive problems)
If the answer to any of the above questions was yes than your patient may qualify for medical reimbursement for their dental implants. The next step would be to determine medical benefits under the patient’s policy. Ensure by asking for benefits on specific codes.
Ensure you are documenting as much of the patient’s medical reasons and history as possible so that appropriate diagnosis codes can be chosen and applied to the claim. Referrals from the patient’s primary care and gastrointestinal specialist can also be instrumental in filing a well-supported claim. Medical benefits can be an excellent starting point for patients who need extensive dental work to alleviate their medical conditions but are limited by their dental plan.
Hermie EnDeePenDent
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Sue Kling
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Julie Ann Knox
My dentist has recommended several implants-I already have one. I have Medicaid. He said it’s hard to prove that implants are medically necessary. I have some digestion issues due to the missing teeth, but it sounds like he doesn’t think this is enough to have Medicaid pay through my health insurance. It sucks.
Sue Kling
In my experience many dentists aren’t willing to put in the effort on your behalf. Don’t be discouraged keep looking for a dentist who is knowledgeable & compassionate. Good luck! I’m in the same boat but I refuse to give up
Rachael Perales
I am missing most of my teeth on the bottom i have 3-4 teeth that are in awful shape, and on top i have none except for some broken pieces along the gum line, i have medi-cal/denti-cal basically equal to medicaid, i am diabetic and unable to eat much due to the lack of teeth, would it be a medical necessity for me to get full implants?
Lisa Kelly
I had a gastric bypass several years ago. Due to this, I am unable to digest food properly. I have dentures, but it is becoming almost impossible to eat properly, due to bone loss in my upper and lower jaws. As a result, I don’t get all of the nutrients that I am supposed to consume. It is very detrimental to my health, to the point that I have had to have infusions several times. I have GERD, had ulcers, and it is a real struggle to eat. I have dental insurance, but only a benefit of $1000 a year. Is it possible that my medical would help cover the cost of 4 on 4?
Peter StClair
Advice for how to go about implants due to having a hard time eating and digestion to meat . Blue cross blue shield is what my insurance.. front teeth and back top and bottom missing . .
Michelle J
Have teeth that are decayed and teeth broken down to the gum. I have had 3 consultations and they have all come back with the recommendation of extracting then replacing all of my teeth. With limits on dental insurance plan, it’s impossible to be able to afford the All-in-4s. I am convinced that dental insurance is made for those with healthy teeth.
Richard Brooke
I have no teeth currently and have had HIV for 4 years and I have a brain tumor and spinal canal stenosis with bone loss in the jaw and neck bone and spinabifida, and in vitro lead poisoning. I have no money and no credit much, and need dental implants to eat would I qualify for medical necessity for dental implants?
Jamie King
I am so sorry to hear about this. Unfortunately, I am not a doctor. So, I would suggest scheduling a consult with a dentist or doctor who can help give you sound dental and medical advice. We wish you all the best.
ShelbyG
Thank u 4 clarifying!! I went on Google, looking 4 a short list of pre-existing and/ or resulting health conditions, that would qualify the required extensive dental work a ‘medical neccesity’ and as such, covered by insurance.
Jamie King
You’re welcome for the clarification, Shelby. We make it our mission to provide you with the most up to date information, so that your patients don’t have to worry about their out of pocket costs.