Establishing Medical Necessity for Dental Implants for Insurance?
Posted in advice Treatment Planning & Complications
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Subscribe to this PostDr. 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.
As you may know, the standard of care for lower dentures is a two implant overdenture. I send a narrative and reference the Wickline and Wilson Cases (research this if you are unfamiliar) which transposes liability to the insurance company and they pay. If the patient cannot eat properly and is losing weight with a convential denture, send a Wilson/Wickline letter and they’ll get covered.
Dr. Stanton, do you have more information about the Wickline and Wilson Cases?
We have been getting some implants covered by medical insurance. The ICD-9 codes are for disuse atrophy, and alveolar atropy (classified as minimal, moderate, and severe).
There is a coding course given by Implant Seminars that is excellent!
Dr. Stanton, in the past we have worked with the patients Md. to include a letter from him/her stating the medical need for implants. I did Google Wickline & Wilson, but only came up with the particular case date. Are you referencing them in your cover letter or is there a specific letter about them. Thanks, J.LoPinto
Dr. Jain,
Perhaps they are referring to the following court proceeding?
Wickline v State of California, 183 Cal. App. 3d 1064 – California court found public insurer liable for a medically inappropriate decision resulting from defects in the cost containment measures. The court found that the insurer had arbitrarily ignored and unreasonably disregarded an appeal for an extended hospital stay. As a result, the patient suffered amputation of a leg as a result of alleged premature discharge from hospital.
Best regards,
MK Cantwell
IF A PATIENT NEEDS A HIP REPLACEMENT DO THEY NEED A DENTAL REASON???.IT SEEMS THIRD PARTY FUNDERS LOVE TO CHARGE CLIENTS 2008 SUBSCRIPTION BUT PREFER TO COVER 1965 TREATMENTS. I WOULD OFFER A FREE DENTAL CLEARANCE TO THE FUNDER AND THEN THEY CAN CHEW ON THE INDICATIONS FOR AN INTERVENTION THAT HAS BEEN CONSIDERED THE STANDARD OF CARE FOR THE LAST FEW DECADES AND WHICH IS SUPPORTED BY VOLUMINOUS SCIETIFIC PUBLICATIONS. TELL YOUR PATIENT TO FIRE THE INSURER AND GET DECENT VALUE FOR THEIR CONTRIBUTIONS.
The ADA states that care is medically necessary for the purpose of :controlling or eliminating infection,pain and disease;and restoring facial configuration or funtion necessary for speack, swollowing or chewing.
Greetings,
KS
I think that you have to read accurately the paper of the insurance of your potential patient. What covers and what not. than see if the subject has difficulties in mastication and pain or rumors at temporo-mandibular joint and others simptoms. at least if the patient needs effectively the substitution of lost dentures and you must too consider her/his professional side.
hello, i think if people can not chew properly they cannot digest there food properly which causes stomach problems down the road. I cannot wear my bottom plate and this is happening to me. So, yes, i consider this a medical problem, and medical should pay for some of this.
I have upper and lower partials for my molars and was wondering if you think the Wickline and Wilson letter would work for me? Im not able to use the partials because they cause alot of pain. my eating habits have definitely changed, I’ve lost weight and the depression is really starting to weigh on me.