Sample letter of medical necessity for dental implants

Dr. W asks:

I am dealing with an insurance company that handles both medical and dental claims. Apparently they will pay for dental implants if I can establish that there is a medical necessity for the dental implants. I have no idea what that means. How is a dental implant a medical necessity? Could someone who has had this problem please help me with this. Without the insurance company payment, the patient will not get the dental implants. I have looked through the literature and have not been able to find anything about this. Would be interested in readers comments.

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 coverage, or their plan excludes implants, or annual maximums leave thousands of dollars 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 is medically necessary by sending complete documentation to the right company.

Oral surgeons offer the best odds of success because they have experience submitting claims to health insurance companies such as Blue Cross & Blue Shield.

Sometimes people ask the wrong questions. For instance, the query, what health insurance covers dental implants suggests that shopping for a new policy answers their dilemma. Drop the shopping around approach.

Free grants for dental implants sometimes help a little. But your health insurance might pay much more if you can prove they are medically necessary.

Medicaid

Medicaid covers dental implants under the health insurance component when medically necessary. However, each state runs the federal program for citizens in their region, and they often select private companies to administer claims.

Managed Care Organizations (MCO) operate the claims underwriting process for Medicaid under contract through the states. Submit the letter of medical necessity to the MCO listed on your member ID card for a final determination.

Name-brand insurance companies operate as MCOs for Medicaid, often in many states, so don’t feel bad if you find it confusing. You are not alone if your plan is managed by Aetna, Caresource, Fidelis, Humana, Molina, United Health Care, or Wellcare.

Medicare

Medicare could cover dental implants when medically necessary, as described above. However, seniors with qualifying health conditions should verify that they send the letter and documentation to the correct organization.

Seniors with regular Medicare Parts A & B should submit their documents to the Centers for Medicare & Medicaid Services (CMS)

Seniors with Medicare Advantage plans should direct their correspondence to the private company managing the policy, such as United Healthcare, Humana, BCBS, CVS Health, and Kaiser Permanente.

Blue Cross

Instead of asking whether Blue Cross medical insurance covers dental implants begin working with your doctor and dentist to verify that you have a medically necessary reason.

Blue Cross Blue Shield (BCBS) is a national federation of thirty-five independently owned and operated insurance companies that set their claims underwriting standards individually.

Send the letter of medical necessity to the specific (1 of 35) BCBS company issuing your policy. They are the final authority on the subject – not this article and indeed not posts in online forums.

Does Health Insurance Cover Dental Implants?

Dental implants are covered by health insurance when you can prove that the treatment is medically necessary. Qualifying services are “appropriate to the evaluation and treatment of a disease, condition, illness, or injury and are consistent with the applicable standard of care.”

Sample Letter

Have your provider follow this sample outline for a letter of medical necessity for dental implants. The goal is to convince your health insurance company to cover the procedure.

• Patient name and member ID number
• SOAP Notes (Subjective, Objective, Assessment, Procedure)
• Summary of medical history and diagnosis
• Rationale for treatment
  • How it treats a disease or illness
  • Why is it consistent with the applicable standard of care
  • The reason that removable dentures are insufficient
• Proposed operative report
  • Appropriate ICD-10 and CPT codes
  • Prognosis or expected outcome

Necessary Reasons

Patients with medically necessary reasons can get their health insurance to pay most of their dental implant expenses – excluding deductibles, copayments, etc.

The cost of full-mouth implants with insurance could be the lowest for patients fitting into any one of these categories.

1. Prevent further bone atrophy caused by diseases such as diabetes, digestive disorders, or osteoporosis
2. Restore chewing function after a non-biting accident fractures the jaw and dislodges teeth
3. Replace teeth extracted before radiation treatment for cancers of the head, neck, and jawbone
4. Lack of dentition worsens digestive disorders such as gastric reflux disease or ulcerative colitis
5. Prescription drugs covered by the plan caused dry mouth and decay leading to tooth loss
   1. Antacids
   1. Antihistamines & decongestants
   1. Blood pressure medications
   1. Antidepressants

Necessary Treatments

Sometimes you can get medical insurance to cover specific dental implant treatment costs even when you do not suffer from one of the health conditions discussed above. Some interim steps are medically necessary by themselves.

Extractions

Health insurance routinely covers bone-impacted wisdom teeth removal, which is medically necessary because they can cause pain and infection and develop cysts.

An oral surgeon may need to extract any remaining bone-impacted teeth as an initial step for full-mouth restorations such as the All on Four technique.

CT Scans

Your medical insurance might pay for the CT Scans 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 are medically necessary when your dentist suspects oral cancer and needs an image of the upper and lower jaw for a proper diagnosis. 

Chose an Oral Surgeon

Choosing an oral surgeon to compose your letter of medical necessity is the most critical step to getting your medical insurance to cover dental implants because they have the most experience.

Health insurance covers many other oral surgery procedures. The back-office operation knows the coding requirements and has probably submitted claims to your carrier many times in the past.

Oral and maxillofacial surgeons are licensed physicians and dentists. Their dual credentials help them compile the appropriate documentation regarding your illness or injury and treatment plan, which they can turn over to their battle-hardened staff.

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