Getting medical insurance to cover dental implants could make replacing your teeth more affordable.
Many patients do not have dental coverage, their plan excludes implants, or annual maximums leave thousands in unreimbursed expenses.
A reasonable cost for a single tooth implant is about $4,000, while a full-mouth restoration could set you back up to $90,000.
There is one trick to avoid this pain. Prove that the treatment step is medically necessary by sending complete documentation to the issuing company.
Oral surgeons offer the best odds because they have experience submitting claims to health insurance companies such as Blue Cross & Blue Shield.
How To Get Health Insurance to Cover Dental 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 dental implants sometimes help a little. But, your health insurance might pay much more if you can successfully implement several steps for medically necessary treatments.
The first secret to getting medical insurance to cover tooth implants is to choose an oral surgeon to perform any early treatment steps rather than your local dentist.
Medicare (and other health insurance) covers oral surgery when medically necessary. Many procedures fall into this category; oral surgeons have experience filing these claims. Meanwhile, the office staff supporting a dentist or prosthodontist may not be familiar with medical billing lingo (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.
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.
The dental procedures covered by medical insurance are medically necessary, and several early-stage steps fall into this category for many patients. Pre-certify before each service and submit a claim after completion of each step.
Health insurance covers tooth extractions when medically necessary. Your prosthodontist may recommend pulling one or more molars, canines, or incisors to prepare your mouth for implants.
Extractions your medical insurance might cover include the following:
- Bone-impacted third molars
- Before radiation treatment for cancer
- After a non-biting accident, dislodging teeth
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:
- Before radiation treatment for cancer
- After a non-biting accident, dislodging teeth
- Diagnosis of jaw Osteonecrosis
- Examine cysts of the jaws or other pathology
Health insurance covers orthognathic 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:
- After a non-biting accident damaging the jaw
- After surgery to remove cancerous lesions
- Replace bone damaged by necrosis
Corresponding with the issuing company before treatment is another crucial element of getting dental implants covered by medical insurance. The carrier might require pre-authorization, pre-certification, and 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
Submitting the appropriate claim form correctly the first time is another crucial step toward getting medical insurance to pay for dental implants. Each carrier will have specific requirements, often needing 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.
The ADA dental claim form might be appropriate after a non-biting accident dislodges teeth requiring a permanent replacement option such as implants. Pay close attention to Line 45 (Treatment Resulting From):
- Occupational Illness or Injury: Worker’s Compensation would be primary
- Auto Accident: Car insurance would be primary
- Other Accident: Medical insurance would be primary
In other words, you might have to submit your claim to Worker’s Compensation or your auto insurance first, depending on where and how the trauma occurred.
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 be familiar with the required codes.
- International Classification of Disease (ICD)
- Current Procedural Terminology (CPT)
Proving Dental Implants Are Medically Necessary
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.
Healthcare.gov defines medically necessary 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 have a different definition.
It is more challenging to prove that a specific dental implant procedure step is medically necessary for some illnesses than others. Sometimes, the tooth loss occurs in conjunction with a covered treatment, while other times, years later.
A Health Saving Account (HSA) might cover dental implants even when your medical insurance does not. An HSA is a tax-favored option bundled with a High-Deductible Health Plan (HDHP).
It is easier to prove the medical necessity of a dental implant treatment step when tooth loss is inherent in another covered procedure. For instance, removing teeth before radiation treatment for cancer of the neck or mouth establishes the need for other services to restore chewing function.
With other illnesses, tooth loss presents years after the diagnosis and treatment of covered medical interventions, making it more challenging to prove medical necessity.
For instance, any of these illnesses would require superior documentation (SOAP notes, LMN, and operative report):
- Lack of dentition worsens digestive disorders such as gastric reflux disease or ulcerative colitis
- Prevent further bone atrophy caused by conditions such as diabetes, digestive disorders, or osteoporosis
- Prescription drugs covered by the plan caused dry mouth and decay, leading to tooth loss
- Antihistamines & decongestants
- Blood pressure medications
It is easiest to prove that a specific dental implant procedure step is medically necessary after an accident because the injury (tooth loss and damage to chewing function) often presents 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 O in SOAP notes makes establishing medical necessity a slam dunk. The objective evidence is easily verified. The patient suffered trauma on a specific day with supporting evidence from related claims (ambulance ride, hospitalization, surgery, etc.).
Does BCBS to Cover Dental Implants
Many patients wonder whether Blue Cross Blue Shield (BCBS) covers dental implants. This question leads to confusion. It is better to ask how to convince BCBS to honor claims for the expensive procedure instead.
Full-mouth dental implant costs with insurance are lowest when your medical plan (or any other) picks up most of the charges. Dental plans typically include restrictive annual benefit maximums. So pay close attention.
BCBS Medical Insurance
The steps to getting Blue Cross Blue Shield medical insurance to cover dental implants mirror those outlined above in the first section. Most BCBS health plans will pay for medically necessary care per the published definition of the issuing company.
BCBS is a national federation of thirty-five independently owned and operated insurance companies. Each entity could have a unique definition of medically necessary that the billing department must address.
Also, each BCBS medical insurance plan may have different pre-certification and claims submission protocols. Please do your homework and contact the issuing company to learn their requirements.
BCBS Dental Insurance
Getting Blue Cross Blue Shield dental insurance to cover tooth implants is more complicated. There are thirty-five independently owned companies, and each organization markets different plans with unique benefits.
Contact the BCBS dental insurance company by calling the phone number published on your member ID card. Verify what benefits and limitations they have for the following procedures.
- Tooth extractions
- CT Scans
- Bone grafting
- Implant surgery
- Abutment insertion
- Installation of a permanent crown