Rose Nierman and Courtney Snow write about the possibility of using medical insurance for implants.
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.
Rose Nierman decodes some coding issues when using medical insurance for implants. Read “Medical billing for bone grafts, oral implants, and CBCT” here:
Rose Nierman is the CEO of Nierman Practice Management (NPM) and creator of the DentalWriter Plus+ software. For over 30 years, Rose has taught dental practices successful & ethical medical billing through the iconic Successful Medical Insurance in Dentistry seminars.
Courtney Snow is the vice president and CE faculty member at NPM. Courtney has helped dental practices bill medical insurance for over 12 years using reliable education, support & software solutions. Contact Nierman Practice Management: [email protected] or 800-879-6468.
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Each one-hour virtual webinar moderated by MedMark Media is equivalent to one continuing education (CE) credit. Credit is available to all who register for the webinar and successfully complete a ten-question quiz through our publication’s online system.
Registrants can attend the webinar live at the specified date and time by using the GoToWebinar join link provided by email from any device with an internet connection. Using a laptop or desktop computer is recommended for best viewing the presentation. If you are using a mobile phone or tablet, we recommend using the GoToWebinar app instead of the web browser to improve ease of use for the webinar’s platform. Registrants will also have access to watch the replay at their own convenience through a link emailed to them within 24 hours of the specified live date and time which is hosted on our publication’s website.
If registrants would like to ask a question or receive further clarification, they can type their questions or comments in the question box of the webinar system. The moderator reminds the attendees multiple times before and after the presentation to use the question box. Questions are addressed at the end of the presentation for at least ten minutes. If any questions come in that are not able to be answered live in the time available, we give the question along with the registrant’s email address to the presenter for them to follow up directly.
Registrants will have to either sign in (previous webinar attendee) or sign up (first-time webinar attendee) for our CE quiz system on our publication’s website. Registrants of all CE webinars are allowed this account free of charge. The ten-question quiz is linked on the replay page below the video as well as available directly through the CE dashboard once the registrant is logged in.
Once the quiz is successfully completed, there is a button to download a PDF of the certificate. A copy of the CE certificate is also emailed to the address on file for the CE account. To ensure the deliverability of emails about CE credits, please:
Check the spam/junk folder in your email account for the email.
If the registrant is having trouble accessing either the live webinar, replay, CE quiz or certificate we are available to help by email, chat, and phone. We can provide simple steps with screenshots on how to navigate to and complete the Webinar CE quizzes.
Legal disclaimer: Webinar expires 2 years from the live date. The CE provider uses reasonable care in selecting and providing accurate content. The CE provided, however, does not independently verify the content or materials. Any opinions expressed in the materials is those of the presenter and not the CE provider. The instructional materials are intended to supplement but are not a substitute for the knowledge, skills, expertise, and judgment of a trained healthcare professional.