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dental benefits are ALWAYS secondary to medical insurance, your omfs did the right thing to file with them first, but may have coded it incorrectly. if the reason for loss of your teeth was due to infection or trauma (not mastication injuries) and you suffered disuse atrophy of the bone, you might get it covered because dental implants in this case would be bone stabilizers the fact that they haver artificial teeth on them is immaterial. your doc could ask for reconsideration and quote Wickline v State of California, 183 Cal. App. 3d 1064, which will usually bump the insurance carrier in favor of covering the case.
Henry Long, DDS
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In my case, the dental insurer has clearly stated that they will cover dental implants and procedures needed before an implant (e.g. bone grafts, etc.) upto 50%. Also they have stated there's no requirement to send anything to my medical insurance first.
I'm not understanding why my doctor's office will not contact my dental insurance when my insurance has agreed to pay 50% of the bone graft procedure.
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Hi guest!
Great question. The reason the pre-authorization may have been submitted to the medical insurer is that some medical insurers and policies do cover dental implants if they are medical in nature. For example, if a patient is in a car accident and enough teeth are missing that it is causing the patient to have problems while eating (problems masticating), then it could be deemed medical in nature and covered by the medical insurer. Of course, some medical policies do have a written exclusion for dental implants and services leading up to the implants as well, as you have found, especially for cases where the implants are being placed for a primarily cosmetic reason. For certain procedures, some dental insurers will require that the dental office bill the procedure to medical insurance first before they will even process a claim or pre-authorization.
Hope this helps, have a great day
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I need 2 implants for molars in the upper right of my mouth. Since the tooth were extracted a few years ago, there's not enough bone to hold the implant. My oral surgeon told me I need bone grafts. His office submitted the pre-authorization for this procedure to my medical insurance company with a medical code 21210.
It came back denied stating that "... per your medical benefit plan, dental implants are excluded from coverage. As dental implants are not covered under your medical plan, any procedure including facial bone graft (21210) performed solely in preparation for a dental implantation is similarly not covered."
So I spoke to my dental insurance, since I felt this should be a dental procedure and not a medical procedure. My dental insurance stated any bone graft, surgery in preparation for dental implant is covered by them at 50%. They suggested using code D7953 and asked to submit the pre-authorization to them instead of under the medical insurance.
My question is - why would the surgeon's office submit this to my medical insurance instead of dental insurance. When I asked the office, they mentioned - due to the nature of grafting, and the amount of grafting needed, they have to submit it under medical and not dental. Since this bone graft is needed in preparation of future dental implants (which is specifically covered by my dental insurance), shouldn't the pre-authorization go to my dental insurance?
Thanks.
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