Dental Implants - Reclaiming a Beautiful Smile
Nothing can brighten a day like a big, happy smile. The best smiles are sweet, toothless, baby grins, but for adolescents and adults, missing teeth may cause embarrassment and make them feel self-conscious about giving those big, beautiful smiles. Beyond the cosmetic aspect, diseased and missing teeth can create or contribute to a myriad of health problems. A malocclusion may result, causing pain in the temporomandibular joint. If multiple teeth are lost, the simple act of eating can be difficult and, in extreme cases, lead to malnutrition.
As far back as early Egyptian civilization, there are records of man’s attempts to solve the challenge of replacing missing teeth, and these efforts have not stopped. It is a well-known historical fact that George Washington had only one tooth in his mouth and wore crude, painful, ill-fitting dentures. A quick Google search yields a wealth of information on early attempts to replace missing teeth with prosthetics made of bone, animal teeth, and human teeth retrieved from cadavers. There is archaeological evidence that the ancient Mayans placed pieces of shell in the sockets of missing teeth. We have certainly come a long way since then!
The concept of dental implants as we know them today began decades ago. Although researchers experimented with titanium for use in the medical field as early as the 1940s, it was a Swedish orthopedic surgeon Per-Ingvar Brånemark who coined the phrase “osseointegrate” in the mid-1950s when he realized that titanium would bond with bone. Brånemark is credited with placing the first dental implant in 1965. It is amazing to think that the science and development of dental implants have progressed so much in just over 50 years. This is the result of many experiments and much research.
The practice of dental implantology has progressed leaps and bounds. Today dental implants are frequently considered the standard of care for the replacement of missing teeth. Many patients’ lives have been changed when teeth lost due to accidents, cancer treatment, andcongenital deformities have been replaced with dental implants.
The question now becomes how to make dental implants affordable for the average patient. Dental insurance payers were initially slow to recognize dental implants as an acceptable, and perhaps preferable, alternative to bridges and dentures. Currently, some plans do allow benefits for implants but these benefits are still limited by a yearly maximum benefit. The actual cost of a single implant varies greatly but it is not uncommon to hear of fees as high as $5,000 or more, including the cost of the restoration. Again, this is for a single implant. A half mouth restoration with implants and crowns or an implant-supported denture could be $25,000 or more. With the typical dental plan’s annual maximum of $1,000 to $1,500, a considerable amount is left as the patient’s responsibility.
Understandably, patients and dentists are seeking alternative sources to assist with these costs. The trend of looking to medical payers for reimbursement has emerged. This seems a natural progression. Diseased teeth, which are deemed non-restorable, need to be extracted to prevent future health problems. This is especially true of patients who may already be medically compromised due to conditions such as diabetes or heart disease. Loss of teeth, especially multiple teeth, can affect patients’ future oral health and eventually their overall well-being. In addition, dental implants have been proven to decrease bone loss, a condition that occurs when teeth are lost. So, why should medical insurance not cover the cost of dental implants?
Sometimes, they do. Stories abound of dental practices that are successful in obtaining reimbursement for dental implants and related services. We are told the key to maximizing reimbursement from medical insurance is to understand what medical payers are looking for in documentation and claims submission. This, in part, is true. It is also important to understand each patient’s medical plan and the specific benefits available for dental procedures.
Most dental implants are still considered to be a dental procedure. However, it is helpful to consider the medical and dental procedure codes available for reporting these procedures. When submitting a dental claim, there are multiple codes available to report the placement of implants and implant related services.
A few of these codes are:
D6010 Surgical placement of implant body: endosteal implant
D6011 Second stage implant surgery
D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant
D6013 Surgical placement of mini implant
Only two codes are available to report the same procedures to medical payers:
21248 Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); partial
21249 Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); complete
While not indicated in the code descriptor, it is generally accepted that 21248 is reported when one to three implants are placed in an arch, and 21249 is reported when four or more implants are placed in an arch.
Note that either of these codes may be used to report the reconstruction of the jaw. These codes are not specific to the placement of dental implants, as described in the nomenclature of dental codes. If you were to contact a medical payer and ask if either of these codes are eligible for reimbursement, the answer would likely be yes. A prior authorization may be required and the final reimbursement may be subject to adjudication at the time the claim is processed. Medical plan documents, however, typically contain language specifically excluding dental implants.
Another point to consider when discussing the possibility of medical coverage for implants is the difference in the focus of dental insurance and medical insurance. The purpose of dental insurance is to help pay for dental expenses, while the purpose of medical insurance is to help pay for treatment of medical conditions. No one expects dental insurance to pay for an appendectomy, yet many patients expect their medical insurance to pay for all oral surgery procedures, including dental implants. On the positive side, medical payers will allow reimbursement for some dental procedures. A wise dental practice understands this and knows when and how to take advantage of this for their patients.
Determining and documenting medical necessity is key. Medical necessity is a term often heard in both dental and medical circles. Simply put, it means the services provided to a patient meet or exceed the accepted standard of care for the condition, illness, or injury being treated. This term applies to the patient’s need for dental treatment as well as the need for medical treatment. There is one very important difference to remember regarding medical treatment – medical payers make a distinction between dental necessity and medical necessity. For a medical payer to consider a dental service for reimbursement, it is not enough to establish that a treatment is necessary for the patient’s oral health. It must be established that the condition and treatment meet the criteria for coverage and benefits of the medical plan.
Contact the patient’s medical plan to determine its exact criteria. Coverage for dental implants is not only payer specific, but also plan specific. Some major payers state that dental implants are excluded unless the individual plans have provisions for such treatment. It is helpful for patients to have a copy of their plan document, which outlines the benefits and exclusions of the policy. The employee can obtain a copy of the plan document from the employer’s Human Resources department or from the payer; the practice cannot.
When a medical plan does provide coverage for implants, there are invariably very specific medical conditions under which implant related services are reimbursed. These conditions, when present, must be accurately and clearly documented in the patient’s clinical record.
While each plan has its own criteria for coverage, there are three basic medical conditions that may qualify the service for reimbursement by the medical payer.
»» Reconstruction following trauma.
»» Reconstruction following cancer treatment
»» Reconstruction for congenital anomalies
It is important to understand that some plans specifically state that dental implants are excluded regardless of reason. When contacting a medical insurance plan for benefits, always be specific and ask if dental implants are a covered benefit. Medical necessity is a moot point when there are exclusions on dental implants; in this case, the implant will not be covered under any circumstance. Remember, always accurately report what you do and the necessity of the procedure.
Is it possible to submit a claim and never indicate that a dental implant was placed and still receive reimbursement? Yes, this is technically possible, but not appropriate, and may be considered fraud.
Consider the following scenario. In this example, Medicare guidelines and policies are discussed since they are readily available to the public, but the concept applies to all medical payers.
A patient presents to the office following an accident in which she suffered a broken jaw. (Note: There is no liability insurance coverage related to this accident.) The fracture repair necessitated the removal of three teeth. The fracture has healed and she is in the office today for a consultation on the replacement of the missing teeth. A treatment plan is presented, which involves the placement of two dental implants. The patient’s medical insurance is a traditional Medicare plan, but she is certain this treatment will be covered because, after all, it is surgery and the teeth were lost due to an accident. She has chosen this dentist specifically because the practice accepts Medicare. The implants are placed and a claim is submitted to Medicare with CPT 21248. The diagnoses listed were:
S02.401S Maxillary fracture, unspecified, sequela (Note: A sequela is defined as a pathological condition that is the consequence of a previous disease, injury, trauma, or therapy.)
K08.25 Moderate atrophy of the maxilla
No mention of dental implants is made in the patient’s clinical record or on the claim. There was a notation made in the record that the patient had a previous fracture and surgery was required to stabilize the bone.
According to the Medicare fee schedule, CPT code 21248 is allowed for reimbursement. As with all Medicare claims, the adjudication is based on the diagnosis reported at the time the claim is submitted. In this scenario there is no mention made of the lost teeth, only the necessity for reconstruction of the jaw. The claim is processed and payment is made.
There is still one crucial point to address in this scenario. The Medicare Benefits Policy Manual clearly states the following as anexclusion from coverage “Items and services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are not covered. Structures directly supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process.“ (Medicare Benefit Policy Manual, Chapter 16, §140) Although the loss of teeth was the result of an accident, Medicare only covers treatment for the fracture. Replacement of the teeth is specifically excluded from coverage.
As previously noted, a provider must always accurately document what services are provided and why they are necessary. In this scenario, there is no doubt that the patient will benefit from the placement of dental implants to replace the missing teeth. However, the placement of dental implants was never documented, despite that it was the purpose for the initial consultation. The failure to document that dental implants were placed, or to report the loss of teeth as a diagnosis on the claim, could be considered fraudulent. If records were audited, this could result in a request for a refund of payments, sanctions, financial penalties, and other legal actions (such as a fraud charge).
Now that we have established the improper way to receive reimbursement from medical insurance, let us consider how we can appropriately obtain benefits for our patients.
First, determine the purpose of the implant and clearly and accurately document it. Documenting a missing tooth and the benefits of a dental implant may establish dental necessity, but not medical necessity. Medical payers want documentation of the reason for the tooth loss and why an implant is required. For example, if the patient has undergone a radical resection of the mandible to remove a malignant tumor, this should be documented along with the degree of bone loss and purpose of placing dental implants. It is acceptable to say that the implants will also stabilize the bone, but do not lose sight of the fact that the primary purpose is replacement of the missing teeth. If the patient’s plan has benefits for reconstruction of the jaw with dental implants, this will be indicated in the plan document.
Second, contact the patient’s medical plan to determine if there is coverage for reconstruction using dental implants to treat the patient’s condition. Be prepared to discuss the proposed treatment plan, including any bone grafting or other procedures required in preparation for the implant. Have the appropriate ICD- 10 diagnoses codes available. If coverage is available, ask if a prior authorization is required and if a request for predetermination of benefits can be submitted.
Third, be upfront and honest with your patient about the possibility of receiving reimbursement from the medical payer. While we may see changes in the future, the current reality is that most medical plans do not provide benefits for dental implants and, as noted, the ones that do have specific conditions to be met.
What can be done to keep the smiles on those patients who do not qualify for medical benefits, to assist with the cost of implants? One suggestion is to explore all options with their dental plans. Some plans may not pay for the implant itself, but alternate benefits may be available for the implant restoration. Do not rule out that some employers have plans that include additional implant benefits. We know of one company that had a dental implant rider written into their medical plan. It took a little digging to find that the coverage was available, but it was well worth the effort when the patient’s five implants were paid in full! While this is an exception and is not typical, it is an example of what can be accomplished with some tenacity.
Even exclusions on medical plans have the possibility of being overturned when sufficient documentation is available to establish the medical necessity of dental implants to correct a patient’s medical condition. Patients should always be involved in their own appeals for coverage. Patients may have avenues open to them that providers do not. For example, they can go to their human resource department and ask for assistance with an appeal to the payer. Even when no insurance reimbursement is expected, assistance can still be available in the form of payment plans with health care financing companies, such as Care Credit.
In summary, when dental implants are in your patient’s future, you may need to “think outside the box” to make that beautiful smile happen. Be persistent in obtaining all benefits available, but always be accurate and honest in reporting the services provided and why these services are necessary.