Dentures - Medical Necessity Criteria

Are dentures covered by Medicare, Medicaid, or commercial insurance?

Contents:

Are dentures covered by insurance?
Medical necessity criteria for dentures
Does Medicare cover dentures?
Does Medicaid cover dentures?
Documentation to Submit
Health plan criteria for dentures and other references

Are dentures covered by insurance?

Dental plans may cover some of the costs of dentures.

Medical plans generally don’t cover dentures but may cover the cost of installing the first denture(s) to replace teeth lost due to accidental injury.

Procedures that are done in order to prepare the mouth for dentures, such as the following, are among the dental services that are NOT covered benefits under medical plans.

Alveoplasty
Dental implant placement and/or bone grafting to support a dental prosthesis
Frenulectomy
Removal of the torus mandibularis or maxillary torus palatines
Tissue conditioning
Vestibuloplasty

Medical necessity criteria for dentures

Dentures, if covered, may be considered medically necessary if the patient has less than eight posterior teeth in occlusion. Some health plans require only less than ten posterior teeth in occlusion for dentures to be considered medically necessary.

Some health plans also consider dentures medically necessary if they are required to stabilize occlusion by minimizing extrusion or tipping of the teeth that the patient currently has.

Partial dentures that replace only anterior teeth is considered purely aesthetic or cosmetic and therefore not medically necessary by some health plans.

Does Medicare cover dentures?

Medicare does not cover dentures. Most dental devices, dental procedures, dental care, and dental supplies are not covered by Medicare.

Does Medicaid cover dentures?

Dentures are covered by Medicaid in some but not all states. Where they are covered, there may be limitations, such as only one set of dentures in a five-year period, in eight years, or in a lifetime. Other states require prior authorization and cover dentures only when are medically necessary.

Documentation to Submit

These are the things you can prepare documentation of in order to support your statement that dentures are medically necessary. Submit only those that apply.

Documentation that patient lacks teeth (“edentulous”):

Patient has less than eight posterior teeth (or ten posterior teeth, for some health plans)

The denture is required to stabilize occlusion by minimizing extrusion or tipping of currently existing teeth

Radiographs

Treatment plan

If the patient has had less than eight posterior teeth for 3 or more years:

Reason why patient has been without a prosthesis for that length of time

Explanation for why dentures are being requested at this time

Analysis of the oral tissue status, such as muscle tone, ridge height, and muscle attachments

Why patient has a favorable prognosis

Documentation that the patient is physically and psychologically able to wear and maintain the prosthesis

Additional documentation requirements for medical necessity of replacement dentures:

Documentation that the prosthesis is six years old or older

Documentation that the prosthesis is beyond repair

Documentation that the prosthesis cannot be relined

Documentation that the base is ill-fitting and prosthesis cannot be relined

Documentation that the teeth are worn and prosthesis cannot be relined

Documentation that there is severe loss of vertical dimension and the prosthesis cannot be relined

Documentation that the prosthesis has been lost, destroyed or stolen, with an explanation of the circumstances

Additional documentation requirements if the request is for cast-metal partial dentures:

Specific reason(s) for requesting cast-metal partial dentures

Documentation of facial deformity due to congenital, developmental or acquired defects

Facial deformity due to congenital, developmental or acquired defects

Additional documentation requirements if the request is for flexible-base partial dentures:

Specific reason(s) for requesting flexible-base partial dentures

Allergic reaction to other denture materials

Facial deformity due to congenital, developmental or acquired defects that would rule out using acrylic or cast-metal partial dentures

Documentation of the following if relevant to patient’s need for dentures:

Bone or tissue changes due to shrinkage

Bone or tissue changes due to recent tooth loss

Bone or tissue changes due to weight loss

Bone or tissue changes due to bone loss in the upper or lower jaw

Bone or tissue changes due to recent sickness or disease

Bone or tissue changes due to physiological aging

Plan of care to wean the patient from parenteral or enteral nutritional supplements

Whether the useful life of the existing prosthesis can be extended by a repair or a reline

Health plan criteria for dentures and other references

Aetna Criteria for Dental Services and Oral and Maxillofacial Surgery
Blue Cross Blue Shield of North Carolina Criteria for Dental Reconstructive Services
California Department of Health Care Services (DHCS) Essential Health Benefits Summary
Florida Medicaid Policy on Dental Services
Illinois Department of Human Services Policy on Dental Services for Adults (Persons Age 21 and Over)
Indiana Health Coverage Programs for Dental Services
Louisiana Department of Health Medicaid Policy on Adult Denture Services
MaineCare Benefits Manual Chapter on Dental Services
MassHealth Policy on Dental Benefits
Medicaid Adult Dental Benefits Coverage by State
Medicare.gov Dental Services
Minnesota Department of Human Services Policy on Dental Benefits for Non-Pregnant Adults
Mississippi Medicaid Administrative Code for Dental Services
New York State Medicaid Program Dental Policy and Procedure Code Manual
Rhode Island Medicaid Policy on Covered Dental Benefits for Children Under Age 21
South Dakota Medicaid Policy on Dental Services
Tricare West Policy on Adjunctive Dental
Washington Apple Health (Medicaid) Policy on Dental Services