When medical insurance covers implant services

Rose Nierman and Courtney Snow discuss common scenarios for medical reimbursement for implants

More than ever, patients are inquiring if their medical insurance will help cover the costs of implant services. The good news is there are situations where implant services and bone grafting are considered medical in nature rather than dental or cosmetic in nature! This is especially riveting news knowing that dental benefits are remarkably limited.

The key to determining whether a case will be considered medically necessary is knowing the criteria medical insurers look for to offer medical reimbursement. Once you have verified specific medical plan benefits, use the correct ICD-10 diagnosis codes, and make your case with a narrative SOAP report to illustrate the medical necessity.

How can we distinguish between cases that might be considered medically necessary and cases that are not? Since insurance criteria vary, the most common scenarios where successful medical reimbursement occurs are listed here.

Accidental injury/trauma, or misadventures of previous medical care

An example from a medical insurer’s coverage policy states implant services may be covered “when the procedure is intended primarily to improve/restore bodily function or to correct significant deformity resulting from accidental injury, trauma, or previous therapeutic process.” It is important to note that injuries from chewing and biting typically do not meet this requirement.

Tumors/cysts of the jaw

When removal of a tumor or cyst requires the removal of sound natural teeth, implant services to replace those teeth are commonly covered as a medical expense. Services that are typically considered dental in nature are frequently regarded as medical when they are required to perform another medical in nature procedure.

Functional impairment

Functional impairment refers to difficulty or inability to complete activities of daily living. Examples in the dental practice realm are patients unable to speak, swallow, or masticate properly. One medical insurer’s coverage policy states implant services may be covered when “the procedure is intended to correct defects and anomalies when they result in a functional impairment.”

Severe atrophy and inability to wear a prosthesis

A patient suffering from severe atrophy (bone height of less than 15 mm) who is also unable to tolerate or accommodate a dental prosthesis may also experience other issues as a result. An example from a medical insurer’s coverage policy states implant services may be covered when “trials of mandibular prosthesis have failed.” The policy clarifies these problems “may include, but are not limited to, malnutrition, persistent pain, gingival ulcerations, and/or mucosal hypertrophy due to instability and upper intestinal problems.”

Now that you know medical reimbursement for implant services is possible, the time is now to start collecting this information from your patients. As you can see in the most common scenarios where medical reimbursement is successful for implant services, a thorough patient intake is crucial to determining the probability of the case being considered medical. This intake should include the patient’s chief complaints, systemic medical history, and symptoms that the patient is experiencing with a focus on problems arising from these issues. These problems may include previous trauma, malnutrition, pain, digestive issues, and functional impairments.

To be successful, it’s what you do upfront that counts! Ensure that you are gathering vital information. We encourage dental practices to have their patients complete Nierman Practice Management’s Medical Necessity Online Questionnaire to gather these imperative details before the evaluation.