Establishing Medical Necessity for Dental Implants

September 24, 2018

More and more dentists are seeking the option to bill dental implants, particularly 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.

Determine Medical Necessity for Dental Implants 

Several questions can be asked to determine medical necessity for dental implants 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 is yes then your patient may qualify for medical reimbursement for their dental implants.

Determine Medical Benefits

The next step would be determining medical benefits under the patient’s policy. Be sure to ask if benefits are available for 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.

If you are struggling with billing overdentures, consider partnering with eAssist. Our Success Consultants have extensive knowledge of dental codes and will accurately bill your claims to obtain reimbursement. To find out more schedule a free consultation here.