Getting your medical insurance to cover some of your dental implant costs could make replacing your teeth much more affordable.

Many people do not have dental insurance, or their plan does not cover implants, or annual maximums leave thousands of dollars in unreimbursed expenses.

The average cost of an implant for a single tooth is about $4,000 – without additional services such as bone grafting or sinus lifts. Then, a full-mouth restoration could set you back up to $90,000.

The trick is establishing a link between a covered accident or illness. Your health insurance may cover the medically necessary steps. Now that is something to smile about!

Private Medical Insurance for Dental Implants

Private medical insurance will often pay for dental implants when treating the after-effects of a covered accident, illness, or condition. Do not waste your time searching for dentists who accept your carrier, or asking if they cover the procedures.

Instead, learn how to show medical necessity. It is like finding a grant for free care.

Medically Necessary

Your private health insurance plan could cover several dental implant procedure steps when your provider can establish that a treatment is medically necessary.[1] Qualifying service is “appropriate to the evaluation and treatment of a disease, condition, illness, or injury and is consistent with the applicable standard of care.”

Accidents

Demonstrating that dental implants are medically necessary is most evident when an accidental non-biting injury causes tooth loss. For example, a senior citizen on Medicare could trip and fall and easily dislodge several teeth that then need replacement.

After the injury, the first step would be to visit a licensed physician who might stitch up lacerations on your face, and order x-rays to check for jaw fractures. The doctor would then bill your medical insurance for reimbursement.

The same plan might then honor claims for any subsequent services provided by your oral surgeon or implantologist. Procedures to restore your chewing function represents appropriate treatment for a covered accident.

Illnesses

Establishing that a dental implant procedure is medically necessary for disease-related reasons follows a similar pattern. If a licensed physician provides care for covered illness and bills your medical insurance first, you have created a connection that the claims adjuster can follow through to your oral care provider.

Below is a partial list of covered illnesses that often lead to tooth loss.[2]

  • Gastro-Esophageal Reflux Disease (GERD)
  • Cancer of the neck and mouth
    • Extraction of teeth before radiation
    • Reconstruction after excision of a tumor
  • Temporomandibular Joint Dysfunction (TMD or TMJ)
  • Bone loss (osteoporosis) of the jaw
  • Diabetes
  • Side effects of drugs (prescription and illegal)

Dentists Accepting

Looking for dentists who accept medical insurance for implants is the wrong strategy. Almost every provider would be thrilled to take payments from your plan because it helps their practice get patients into chairs.

Narrowing your search to dentists who understand how to bill your health insurance is a better approach. You need to find a practice with an office manager who has experience writing letters of medical necessity.

Specialists are more likely to have this expertise.

  • Oral and maxillofacial surgeons often have medical degrees and routinely bill for a host of related services.
  • Periodontists routinely prescribe antibiotics to treat gum disease (gingivitis) and pain medication when performing surgery

Insurance Companies

Asking if your existing medical insurance company covers dental implants is another poor strategy. Carriers such as Blue Cross Blue Shield, Aetna, Cigna, and Metro Plus Health all adhere to similar claims underwriting principles and must comply with the same state and federal regulations.

A better approach might entail contacting your issuing company assisted by the office manager at your oral surgeon. The letter of medical necessity could make a case for each procedure step, with emphasis on the earlier operative procedures.

The outcome could be a phased payment plan with time baked in for healing, funded in part by your insurer. The earlier steps are most likely to qualify for coverage.

  1. Tooth extractions
  2. Cone Beam Computed Tomography (CT)
  3. Bone grafting
  4. Sinus lift
  5. Body placement
  6. Abutment insertion
  7. Installation of dentures

Public Health Insurance for Dental Implants

Public health insurance programs follow similar parameters for when they cover dental implants. Senior citizens, disabled adults, and low-income families qualify for coverage funded primarily by taxpayer dollars.

However, the rules for Medicaid are quite different than for Medicare.

Medicaid

Medicaid is a public health insurance program jointly run by federal and state governments. Medicaid often pays for dental implants for low-income adults when medically necessary as with private coverage.

However, Medicaid also covers dental work for adults in some regions when not connected to an accident or illness. Each state makes its own rules about the types of oral care procedures covered. Therefore, the possible payments for each implant phase are all over the map.

For example, Medicaid covers oral surgery in twenty-four states and removable dentures in twenty-six. Living in one of the states boosts your odds of help with some of the treatment steps.

Oral SurgeryDentures
Arizona  
CaliforniaXX
Florida X
Georgia  
IllinoisXX
MassachusettsXX
Michigan  
New JerseyXX
New YorkXX
North CarolinaXX
Ohio X
PennsylvaniaXX
Texas  
Virginia  
Washington  

Medicare

Medicare is a public health insurance program run by the federal government for retired senior citizens and adults with permanent disabilities. The Medicare rules for dental implant coverage are more restrictive due to a statutory exclusion related to oral care.

“services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.”

The government provides two examples of just how limiting the statutory exclusion is when putting into practice. It draws a clear line making it difficult to cross.

  • The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease
  • Reconstruction of the jaw following an accidental injury

However, seniors enrolled in Medicare Advantage plans could enjoy more leeway as some of these Part C programs provide coverage for dental work. Check with the insurance company issuing the coverage for details.

Footnoted Sources:

[1] Implant Practice US Medical Billing

[2] Dental Medical Billing: Restorative Treatments