Getting medical insurance to cover dental implants could make replacing your teeth more affordable.
Many patients lack dental coverage, have plans that exclude implants, or face high unreimbursed expenses due to annual maximums.
A reasonable cost for a single tooth implant is about $4,000, while a full-mouth restoration could cost up to $90,000.
You can avoid these high costs by proving the medical necessity of the treatment and providing thorough documentation to the insurance company.
Medically Necessary Implants
Getting tooth implants covered by medical insurance is not easy. Still, it could be worth the extra effort as dental plans rarely cover the total cost. Annual benefit maximums of $1,500 do not stretch far.
Free government grants for tooth implants are a fantasy. However, coverage from your health insurance could become an actuality if you follow the correct claim filing procedures.
Oral Surgeon
The first secret to getting medical insurance to cover tooth implants is to choose an oral surgeon rather than your local dentist to perform any early treatment steps.
Medicare and other health insurers cover oral surgery when it’s medically necessary, and oral surgeons are skilled at filing these claims. In contrast, dental office staff might not know medical billing terms such as ICD and CPT codes.
Getting the appropriate documentation right the first time translates into paid claims, and oral surgery offices should do a better job because they do medical billing regularly.
Treatment Stages
The second strategy for getting medical insurance to cover dental implants is to break down the treatment by procedure, which occurs in stages over months rather than a single day.
Health insurance covers medically necessary dental procedures. For many patients, this includes various early stages of tooth implant treatment. Ensure you pre-certify each stage and submit individual claims upon completion.
Tooth Extractions
Health insurance covers tooth extractions when medically necessary. Your oral surgeon may recommend pulling one or more molars, canines, or incisors in preparation for receiving dental implants.
Extractions your medical insurance might cover include the following:
- Bone-impacted third molars
- Before radiation treatment for cancer
- Teeth dislodged in accidents not involving biting
Oral surgeons are more likely to accept your medical insurance than a prosthodontist or general dentist for these tooth extractions. Using an in-network provider lowers costs considerably as they cannot charge more than the allowed amount.
CT Scans
Your health insurance could cover a computerized tomography (CT) scan performed by the oral surgeon or prosthodontist to measure the height and width of your jawbone so they can place the appropriate dental implant and avoid nerves and sinuses.
CT Scans might be medically necessary in these situations:
- Evaluating bone structure and anatomy before radiation treatment for cancer
- Assessing the extent of dental injuries when teeth are dislodged in non-biting accidents
- Diagnosing Osteonecrosis of the jawbones
- Examining cysts or other pathologies of the jaws
Bone Grafting
Health insurance covers corrective jaw surgery when medically necessary. An oral surgeon might recommend bone grafting if the mandible or maxilla is too thin or soft to support a dental implant.
Bone grafting might be medically necessary in these situations:
- Repairing jaw damage resulting from non-biting accidents
- Reconstructing areas after the surgical removal of cancerous lesions
- Restoring bone lost to necrosis
Pre-Certification
Before treatment, please consult with your insurance provider regarding their coverage process for dental implants, which may be referred to as pre-authorization, pre-certification, or pre-determination.
Dental implant medical coding requirements can include three elements submitted and reviewed in advance in the pre-certification process.
- SOAP Notes (Subjective, Objective, Assessment, Procedure)
- Subjective: What the patients report about their health
- Objective: Facts that can be verified or observed
- Assessment: The provider’s conclusions, diagnosis, or prognosis
- Procedure: Specific treatment that the dentist will provide
- A Letter of Medical Necessity (LMN) is a narrative providing the treatment rationale
- An Operative Report documents the details of the surgery for the patient’s medical records
Claim Submission
Accurate initial claim submission is vital to securing medical insurance coverage for dental implants. Due to each carrier’s specific requirements, this often requires the expertise of a seasoned medical biller.
The carrier might require submission of an American Dental Association (ADA), Center for Medicare & Medicaid Services (CMS), or other claim form.
ADA Form
When completing the ADA dental claim form for teeth dislodged in a non-biting accident that necessitates dental implants, it’s critical to correctly identify the incident on Line 45 (Treatment Resulting From) to determine the primary insurance coverage.
- Worker’s Compensation for occupational injuries
- Car insurance for auto crashes
- Medical insurance for other accidents
CMS Form
The CMS-1500 claim form is the standard document to submit for Medicare, and many private insurance companies will accept this document when a covered illness leads to tooth loss.
Verify that the office staff is familiar with the CMS-1500 or the equivalent required by your carrier. The billing specialist should know the industry codes to communicate information uniformly.
- International Classification of Disease (ICD) describes diagnoses, symptoms, and procedures.
- Current Procedural Terminology (CPT) describes medical, surgical, and diagnostic services.
Proving Medical Necessity
Proving that specific dental implant treatment steps are medically necessary is crucial to getting your medical insurance to cover each procedure. The pre-certification process noted above must address the definition published by the carrier issuing your plan.
Government Definition
Healthcare.gov defines medical necessity as “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.”
However, your plan might define medically necessary differently. Therefore, it is crucial to review and understand the specific definition outlined by your insurance plan.
The dental implant pre-authorization must prove that each procedure step is medically necessary as defined by your plan – not the government.
- Understanding the nuances of one’s coverage can significantly impact the approval process.
- Collaboration can ensure that all documentation and justifications are in place to meet the insurer’s requirements.
Medically Necessary Illnesses
Proving the medical need for a specific step in a dental implant procedure is more complex for some illnesses than others. Tooth loss can sometimes occur during a covered treatment but can also happen years later.
A Health Savings Account (HSA) might cover dental implants even when your medical insurance does not. An HSA is a savings option with tax benefits that comes with a high-deductible health plan.
Immediate Illnesses
Proving a dental implant is medically necessary is simpler if tooth loss is part of a treatment that is already covered. For example, if teeth are removed for neck or mouth cancer treatment, this shows a clear need for dental work to restore chewing.
Delayed Illnesses
When tooth loss happens years after treating other illnesses, it is harder to show it is medically necessary. For these conditions, detailed records such as SOAP notes, letters of medical necessity (LMN), and surgery reports are needed:
- Missing teeth can make digestive problems like acid reflux or ulcerative colitis worse.
- Dental implants can help stop further bone loss in patients with diabetes, digestive issues, or osteoporosis.
- Some prescription drugs the plan pays for can cause dry mouth and tooth decay, which may result in tooth loss.
- Antacids
- Antihistamines & decongestants
- Blood pressure medications
- Antidepressants
Medically Necessary Accidents
Proving the medical necessity for a dental implant is straightforward after an accident, as tooth loss and chewing problems usually appear immediately.
Health insurance is the payer when a patient experiences significant trauma to the mouth or jaw. The tooth loss is often immediate and obvious. With accidental injuries, the pre-certification process is straightforward.
For example, the ‘Objective’ part of SOAP notes clearly shows when a dental implant is needed. It’s easy to check the facts. The patient had an injury on a particular day, and there are records to prove it, like the ambulance service, hospital stay, and any operations.
