If medical insurance covers dental implants, your proposed treatment plan will be more affordable.
Many patients lack dental coverage or have limited benefits due to yearly caps and exclusions for missing teeth.
A single tooth implant costs about $4,000. A full-mouth restoration can cost up to $90,000.
Proving the treatment is medically necessary can help you avoid these high costs. Provide complete documentation to the health insurance company and check back with them regularly.
Early Procedure Steps
Some patients can get medical insurance to cover specific treatment steps, and some early-stage dental implant procedures can be medically necessary on their own.
You do not have to worry about missing tooth exclusions. The Affordable Care Act requires health plans to cover pre-existing conditions without a waiting period.
Imaging Studies
Health insurance might pay for imaging studies associated with a covered illness or accident. Oral surgeons often use computerized tomography (CT) scans to measure the height and width of your jawbone.
The measurements help them place the dental implants to avoid nerves and sinuses. CT Scans might be medically necessary in these situations:
- Evaluating bone structure before radiation treatment for cancer
- Assessing the extent of dental injuries caused by non-biting accidents
- Diagnosing osteonecrosis of the jawbones
- Examining cysts or other pathologies of the jaws
Tooth Extractions
Medical insurance often pays for tooth extractions when medically necessary. Your oral surgeon may remove several teeth to prepare your mouth for dental implants.
Health insurance covers tooth removal in these cases:
- Bone-impacted third molars
- Before radiation treatment for cancer
- Teeth dislodged by accidental mouth trauma
Jaw Surgery
Health insurance covers corrective jaw surgery when medically necessary. An oral surgeon might recommend bone grafting or alveoplasty to prepare your mandible or maxilla for dental implants.
Medical insurance pays for orthognathic surgery in many instances.
- Correction of significant congenital deformity
- Restoration of function following injury, infection, or tumor
- Treatment of malocclusion creating a functional deficit
- TMJ dysfunction
- Sleep apnea
- Speech abnormalities
Later Procedure Steps
Your oral surgeon must prove that dental implants are medically necessary. If so, your health insurance should cover late-stage treatment steps like implant surgery, abutment insertion, and crowns.
Medicaid does not cover tooth implants under its health insurance component unless medically necessary. However, New York and California offer extra dental benefits.
Policy Definition
You must prove that dental implants are medically necessary based on your health insurance policy’s definition. No uniform standard covers implant surgery, abutment insertion, and crowns.
For example, Cigna’s definition includes these phrases:
- Diagnose or treat a sickness, injury, or symptom
- Suitable for the health problem
- Within usual standards of care by doctors
- Not more expensive than other options
- Part of another covered treatment
In another example, Healthcare.gov defines the term 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.”
Contact your insurance company for a precise statement.
Traumatic Injury
Dental implants replacing teeth lost to trauma meet the primary medically necessary criterion. They treat an injury to your jaw.
However, you may need to prove that they meet the standard of care by doctors. Implants are more expensive than dentures. You will need a compelling reason.
Implants preserve jawbone density by integrating with the bone, which is crucial after a facial injury like a jaw fracture. Dentures may cause bone loss due to lack of stimulation and can affect speech and eating capabilities.
Covered Illnesses
Dental implants, which replace teeth lost to diseases, meet the primary medically necessary criterion. They treat an illness affecting jaw function.
You may also need to prove they are part of another covered treatment. Head and neck cancer patients can make a strong case. They frequently have teeth extracted before radiation therapy to reduce the risk of osteoradionecrosis (ORN) of the jaw.
Reduced saliva production after radiation makes removable dentures problematic. Implant-supported crowns or bridges may be a crucial aspect of the covered radiation treatment. They restore the function of extracted teeth and do not require saliva to work effectively.
Submitting Insurance Claims
Adherence to best practices is crucial to getting medical insurance to cover any dental implant treatment step. The claims process requires extra effort and attention to detail, but it could be worth it.
Medical insurance pays up to 100% of approved charges with no annual maximum or waiting periods. In contrast, most dental plans pay little, if anything.
Oral Surgeon
Choosing an in-network oral surgeon increases the chances of a paid claim. Oral surgeons often bill medical insurance and know the requirements.
Medicare covers specific oral surgeries deemed medically necessary, even though it rarely pays for dental work. This billing experience will also help with implant-related claims with private insurers.
In-network providers agreed to accept the insurance-allowed amount as full payment for services. They charge discounted prices in exchange for patient volume. The regular interaction with claims underwriters boosts approval odds.
Pre-Certification
Contact your health insurance company through your oral surgeon to get prior authorization. Provide details about the planned implant procedure and explain why it is medically necessary.
Insurance companies usually require prior pre-certification before starting complex treatment. They may deny your claim if you don’t get it. So, it’s essential to begin the process early.
Letter of Necessity
“Include a letter of medical necessity with the prior authorization request. The letter should answer key questions the insurance company will ask.
- What sickness or injury will the implants treat?
- Why is the procedure suitable for the health problem?
- Who says the treatment fits the standard of care?
- Is there a less expensive option, and if not, why?
- How are the implants part of another covered treatment?
SOAP Notes
Include SOAP notes in your letter of necessity for dental implants. SOAP notes are a structured method for documenting patient care.
- Subjective: What the patients report about their health
- Objective: Facts that can be verified or observed
- X-rays showing bone loss
- Records of previous procedures
- Assessment: The provider’s conclusions, diagnosis, or prognosis
- Procedure: Specific treatment that the dentist will provide
Billing Codes
Include the proper billing codes in the letter of necessity for dental implants. Medical billing codes identify procedures, diagnoses, supplies, and services.
- CDT — Current Dental Terminology codes
- ICD-10 — International Classification of Disease
- CPT — Current Procedural Terminology codes
Claim Forms
Contact your health insurance company to verify the correct claim form to use. Follow the instructions carefully to avoid unnecessary delays and denials.
The carrier might require different forms for injuries and illnesses.
Injury Form
If you need dental implants to treat an injury, you may need to file an ADA claim form. In specific situations, medical insurance is the secondary payer.
Line 45 on the ADA form asks a crucial question: “Treatment resulting from?”
- Occupational injury suggests that Worker’s Compensation would be the primary payer.
- Auto accident implies that your Auto Insurance policy would be the primary payer.
Illness Form
If you need dental implants to treat an illness, you may need to file a universal claim form. The most common forms are the CMS-1500 and the UB-04.
- CMS-1500 is the official form for Medicare and Medicaid
- UB-04 is the form used by many private insurance companies
Consistency
Regular, clear communication with the insurance provider is vital. Keep a record of all correspondence, dates, and times of contact. Consistency in sending reminders and follow-ups helps keep the process on track.
Persistence is the key to getting medical insurance to cover dental implants. Never give up. Document the medically necessary reason thoroughly, and keep following up!
