Dental Implants - Medical Necessity Criteria
Criteria for documenting medical necessity of dental implants
Contents:
- How can you get dental implants covered by medical insurance?
- Can dental implants be medically necessary?
- Medical necessity criteria for dental implants
- How can you prove that dental implants are medically necessary?
- Frequently Asked Questions
- What are dental implants?
- Are dental implants permanent?
- Are dental implants expensive?
- Can dental implants be removed?
- Can dental implants get cavities?
- Documentation to Submit
- Health plan criteria for dental implants and other references
How can you get dental implants covered by medical insurance?
First, check if dental implants are a covered benefit under the medical insurance contract.
Dental implants and most other dental services are generally NOT covered under medical insurance.
However, there are exceptions. For example, traditional medical plans may cover surgical placement of dental implants when this is done for replacement of teeth lost in a non-biting injury. Other possible exceptions where dental implants can be covered include trauma, congenital anomalies, and orthognathic surgery. In these situations, it must be shown that the dental implant is medically necessary.
Keep in mind that, even if the dental implants and the implant surgery are covered by medical insurance, the health plan may not accept responsibility for the maintenance and/or replacement of future implant fixtures, implant abutments, crowns over implant, or other dental services related to the implant.
Can dental implants be medically necessary?
There are situations where dental implants may be considered medically necessary. One example is in the context of bone and tooth loss that impacts the individual’s ability to chew or breathe. Refer to the specific medical necessity criteria used by the patient’s health plan to make sure that these are met and that the dental implants can therefore be covered.
Medical necessity criteria for dental implants
Dental implants may be considered medically necessary when the following criteria are met:
- The patient has bone and tooth loss that interferes with chewing or breathing, such as when there is tooth loss as a direct result of cancer (or cancer treatment); and
- The remaining tooth and jaw structures are not able to support a functional prosthesis.
Dental implants may be considered unnecessary in cases of inappropriate age, inappropriate alveolar growth or situations where there is no reasonable chance of success.
How can you prove that dental implants are medically necessary?
You must provide sufficient documentation that the patient meets the medical necessity criteria used by their health plan for dental implants. This may include the following documents:
- The patient’s medical and dental history, which should support the medical necessity of dental implants;
- Copies of radiographs (X-rays) that show the patient’s current dental condition; and
- A complete treatment plan of which the placement of dental implants must be an essential part.
The patient’s health plan may require a letter from the patient’s doctor explaining:
- how the implants will alleviate the patient’s medical condition; and
- why other covered alternatives for prosthetic replacement will not be able to correct the patient’s dental condition, making dental implants necessary.
Frequently Asked Questions
What are dental implants?
Dental implants are metal frames or posts that are surgically placed into the jaw in order to support and keep in place dental crowns, bridges or dentures.
Are dental implants permanent?
Yes – dental implants are intended to be permanent. They are designed so that they will settle into the jaw and allow the surrounding bone to grow around and bond with them.
Are dental implants expensive?
Dental implants are sometimes described as a “lifetime investment” because they do tend to be expensive. They cost approximately $3,000 – $6,000 — this includes the implant itself, abutment, and crown.
Can dental implants be removed?
Although dental implants are intended to be permanent, they can be removed. In fact, there are situations when they would need to be removed, such as when there is infection.
Can dental implants get cavities?
Dental implants do not get cavities because they are synthetic — they are not made of actual dental enamel — and so they are not affected by the bacteria, tartar, and plaque that break down teeth and cause cavities to form.
Documentation to Submit
These are the things you can prepare documentation of in order to support your statement that dental implants is medically necessary. Choose only those documents that apply to the patient’s situation.
Health plan criteria for dental implants and other references
- Aetna Criteria for Dental Services and Oral and Maxillofacial Surgery (Coverage Under Medical Plans)
- BlueCross BlueShield of North Carolina Criteria for Dental Reconstructive Services
- EmblemHealth Dental Trauma Guidelines for Medical Plans
- Harvard Pilgrim Health Care Medical Policy and Clinical Review of Dental Services in Medical Benefit
- New York State Medicaid Program Dental Policy and Procedure Code Manual