Dental Implants Covered by Insurance?

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George, a patient, asks us:
I’d like to know if it is possible to have medical insurance cover dental implant procedures? If not, what are the  reasons why insurance would not cover dental implants?

I had a bone graft done and the bone graft was 100% covered by  medical insurance. But the dental implants I’m getting will supposedly not be covered by insurance. Logically the dental implants are the final step in the bone graft procedure, somewhat like pins placed in a broken bone. The implants will keep the bone healthy and stable, maintain my facial structure, allow me to keep up a healthy
mouth which supports healthy nutrition. Shouldn’t it be in the financial interests of dentists and surgeons to lobby to get dental implant procedures covered? Thanks for any comments.

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14 Responses to “ Dental Implants Covered by Insurance? ”

• Anonymous September 19th, 2006

  
  

  Dear George,

  As a practicing clinician, I certainly do sympathize with your concerns of dental implant treatment being covered by dental insurance. The cost of implant treatment is certainly not a decision made without financial consideration.

  You asked “I’d like to know if it is possible to have medical insurance cover dental implant procedures? If not, what are the reasons why insurance would not cover dental implants?”

  Dental implant placement is a procedure which replaces a tooth, which in essence is a DENTAL procedure not a MEDICAL procedure. If the tooth was lost due to an accident or traumatic event like a car collision or tumor, the reconstruction may include implants where the medical insurance may provide coverage. Therefore in the vast majority of cases, medical insurance will not cover a dental procedure. Loosing a tooth from an abscess or decay is a dental problem not a medical problem, and also will be denied for claim since it is of dental origin. For an rough analogy, its like asking your auto insurance to pay for damages to your house from a fire.

  You asked “Shouldn’t it be in the financial interests of dentists and surgeons to lobby to get dental implant procedures covered? Thanks for any comments.”
  -
  You are exactly right in saying loss of teeth does change your facial bone contour and density over time and having an implant will provide more bone preservation and a healthier life in general, but for every patient that can reasonably justify implant placement for their health, there are about 100 more people without any teeth that have managed to survive by keeping up their nutrition… with dentures. Why do I point this out? Therefore in an insurance model which chooses to provide the most cost-efficient treatment to its insured, you will not get the best treatment covered UNDER insurance. The dental insurance company is a business model concerned with making a profit (I’m sorry but its the truth), not necessary in the business for your optimal health.

  Eventually, the dental implant will become an accepted standard of care where the insurance companies will pick up coverage on them, but because of the high price tag for now, it remains an non-covered benefit. You can either decide, to accept the decision of the insurance company of how to choose a treatment plan, based solely on their coverage.

• Joseph E. Margarone III DDS September 19th, 2006

  
  

  I agree with all of the above comments except for the auto insurance vs home insurance analogy. The oral cavity is part of the human body, but unfortunately, there has been an artificial dichotomy between medical and dental care as well as medical and dental insurance coverage. For example, I may have a patient who has a large cystic lesion in their mandible that has eroded bone as well as tooth structure. Upon the lesion’s removal, a tooth or teeth may be necessary to be removed to obtain complete healing. Most medical insurances will cover the cost of the lesion removal (21046 CPT) but they will not cover the cost of the removal of the associated tooth or the other involved teeth in the area. It is pure stupidity, but it is the reality of the stranglehold that the insurance companies have on providing coverage to their whim. It is more like your auto insurance pays for all repairs on your car except for the radiator cooling system, which is part of the car’s function but is determined to be an arbitrary non-covered expense. You would need to get coolant system coverage for that portion of your car. Your oral cavity is certainly part of the GI tract of your body, but it is pretty much ignored by medical insurance coverage.

• Anonymous September 19th, 2006

  
  

  You would have been beter off if the Doctor who placed the bone grafts included the cost of the dental implants. Insurance companies pay for procedures that pay for. There is no regulation on what procedures they cover unless they are challenged legally as they were with Teompormandibular disorders. The problem with the Dentist is that they are unable to collectively challenge the biased changes in insurance coverage. ie: 1. The yearly maximum on dental insurance is $500-$2500- unlimited. Ortodontic coverage is certainly not evidenced based, Pre-existing conditions for crown and bridge is in the benefit of the insurance company, Down coding from crowns to amalgams. It is quite clear who sets these limitations on our patients. Dentist are better off becoming insurance companies because they are less regulated. Good luck with your implants.

• Anonymous September 20th, 2006

  
  

  This discussion needs to being with the golden rule of insurance. Insurance be it medical dental or auto(PIP) is nothing more than a contract between an insurance carrier or TPA and the person whom makes the insurance purchase( most times someone in the HR department of a company). I have experience with medical, dental and PIP paying for both the bone grafting procedure and the implant placement. some plans will do so, others do not. You can appeal the claims, but the coverage is the contracted coverage. To add the fee of the implant into the bone graft has the appearance of insurance fraud.

  There is no debate about the overall dental/medical benefit to this type of treatment. However that is another and totally seperate issue.

• Samuel Schmidt September 20th, 2006

  
  

  Is it true that the reason
  dental insurance and medical insurance does not cover implants is because they are not recognized the American Dental Association? I cannot afford having one without the help from insurance and if something should go wrong and the implant needs to be surgically removed what do I do?

• Anonymous September 24th, 2006

  
  

  Samuel Schmidt: go look under New topics at this site “DEntal Implant Removal” and see all the information that is provided to a patient asking for information regarding implant removal. Very informative..

• George September 27th, 2006

  
  

  This was my question and thanks for these well-thought out responses. A question like that is always a “Well it depends” but these were all useful points.

  I especially like the dentist who point out the “artifical dichotomy” of dental and medical health. How true. With studies showing tentative links between gum disease and heart disease, it is surely unfortunate that insurance companies are involved in deciding via coverage what is and what isn’t medically necessary, and unfortunate that dental and medical are usually considered separately. At times it’s Kafkaesque. And the analogy to the auto insurer paying for some but not all of repair - somewhat arbitrarily - is what I’m facing. It’s good to hear that there is a slight chance I can get my grill fixed and covered after all (pun intended). As with some facial plastic surgery, implants certainly can be viewed as a vanity treatment, but they should also be viewed as the correct medical choices in certain cases, especially with younger patients who have lost teeth and related bone due to trauma.

• Kathy November 9th, 2007

  
  

  I am an attractive, disabled but healthy, 64 year old, living in California.

  Having Medicare and MediCal and an income of only 10,000 a year. I am now faced with needed my four front, capped teeth, replaced with implants. One tooth has just broken off at the gum line four days ago (leaving the root behind).

  A dentist offered to implant the one broken off tooth, for 5,000. But said, the same thing is soon going to happen to the other 3 front theeth, since they are “leaking”. She offered to do all four implants for 20,000.

  I’ve always taken pride in both my appearance (which one’s teeth are a major part) and never going into debt. (My credit bal is zero with a credit line of 5,000).

  Since implants are not covered by my insurances, I’m thinking of have it done in Mexico. But I have no idea if this is adviable and the very thought of all that expensive traveling back and forth may be more than I can handle. (Can we even travel to Mexico these day?)

  Any alternative suggestions would be greatly appreciated. Kathy

• Peggy November 10th, 2007

  
  

  Four year ago my then 18 year old son lost 1/3rd of his upper right maxilla due to an ameloblastoma tumor - along with 4 teeth. That was certainly a medical situation and the replacement of those teeth should be covered by our medical insurance. He recently had an Infuse bone graft to reconstruct his maxilla. If that succeeds, we are definitely pursuing coverage for implants and replacement crowns through our medical insurance.

  When this same son was 11 years old, he lost four top front teeth and his upper front maxilla in a bike accident involving an automobile. The jaw was too fragmented to wire together - all the surgeon could do is remove pieces of shattered bone.

  Our car insurance has paid for all the surgeries, bone grafts, implants, etc for the past 11 years and will continue to cover him until the limits of our medical coverage are reached. Fortunately, we had $100,000 medical coverage so he should be covered for life on his front implants.

  Due to two traumas, covered by two different insurance policies, we have had some interesting experiences in getting payment. Seven years after the bike accident, when my son was fully grown, the ameloblastoma was discovered during preparation for the front jaw reconstruction. The tumor was removed during the same surgery in which the front maxilla was reconstructed utilizing bone from my son’s lower jaw. The auto insurance paid for the jaw reconstruction; the medical insurance paid for the removal of the tumor. The medical insurance also paid for the later radical surgery which became necessary when we discovered that the “cyst” was an ameloblastoma….but didn’t want to pay for the anesthesia because it was a “dental” procedure. Ha!….they did end up paying but I had to appeal their initial decision.

  I don’t know what battles lie ahead with regard to the implants to replace the teeth lost due to the tumor but I expect there will be some. However, due to the fact that the teeth were lost for a medical, not dental, reason I have fairly optimistic expectations that the medical insurance will cover them. Time will tell.

  I think that eventually, the implants will cost less. It will be like other things, once everyone starts getting them (and that seems to be the case more and more), ways will be found to provide service less expensively as the implant materials are manufactured in more volume and more doctors become skilled in the placement of them.

• Kate April 24th, 2008

  
  

  George, how did you get the bone graft covered by medical insurance? My son is having a bone graft procedure done in preparation for 6 implants and they are telling me that the bone graft will not be covered. They are estiamting the bone graft to be 20-25K out of pocket. Ouch!

• Joy July 2nd, 2008

  
  

  Hi George,

  Under what circumstances will an insurance company pay for bone grafting? Must you have a a medical doctor either recommend or perform this surgery instead of an oral surgeon in order to have this procedure covered?

  Thanks,
  Di

• Bruce McKelvy July 3rd, 2008

  
  

  Insurance companies are still paying for bone grafts for bony defects around periodontally involved teeth. We have been unsuccessful in having them pay for bone grafts for ridge augmentation, socket preservation etc which in my opinion have much better success than those for periodontal defects. A number of companies are now helping pay for implants.

• renee carr July 28th, 2008

  
  

  20-25K for bone grafts? Does this include the implants? I had 9 bone grafts done 2 weeks ago and they were only 3000.00 for all 9. I just found out that this has to be coordinated with my health insurance. I doubt they will pay as only 2 had complete bone loss but my dental will pay 70%

• R. Hughes July 28th, 2008

  
  

  Usually not. Good luck!

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