When Are Restorative Dental Treatments Medically Necessary?

You’ve probably heard that medical insurance will only cover restorative treatments or dental prosthetics if they repair damage from a traumatic injury. While it’s true that medical insurance always covers these treatments, many medical insurance policies also cover medically necessary restorative treatments.   Billing medical insurance for these treatments can help your patients afford care that will greatly improve their oral health and their quality of life.

So when is a dental restoration procedure medically necessary? It depends on the condition and on your patient’s medical history. To find out if insurance will pay for a treatment, you need to get a complete picture of your patient’s health.

The Basics of Medical Necessity for Restorative Treatments

Medically necessary restorative treatments correct real, structural damage to the teeth. Purely aesthetic concerns are never covered. Instead, the treatments must address problems that cause a loss of dental function and that impact a patient’s ability to live a healthy life. Damage that increases the risk of infection, causes teeth to break, causes pain, or affects a patient’s ability to eat a varied diet may be covered under a medical insurance plan.

The types of conditions that lead to covered treatments fall into four main categories:

  • Oral effects of medical conditions like diabetes, cancer, or TMD
  • Damage from over-the-counter medications
  • Damage from prescription drugs
  • Damage from illegal drug use

Take a complete medical history of any patient who comes in for restorative or prosthetic treatments. There’s a good chance that the damage to their teeth resulted from earlier medical issues and that it is covered by their medical insurance.

The Most Common Medical Causes of Dental Damage

You probably already provide medically necessary treatments on a regular basis without realizing what you’re doing. By learning to bill medical insurance for these procedures, you can save patients money and increase your reimbursement rates.

For instance, dentists commonly perform restorative treatments for teeth that have been damaged by Gastro-esophageal Reflux Disease (GERD) or Bulimia. Both of these conditions have medical codes associated with them. If you approach the restorative treatments properly, you may be able to bill them to medical, rather than dental, insurance.

To bill medical insurance, you must show how the problem and the treatment relate to an underlying diagnosis. So, for instance, in a case of a patient suffering from GERD-induced damage to the teeth, you would compile clinical notes describing the degree of etching, a letter of medical necessity (LMN) from your practice explaining why the restorative treatment is necessary, and an LMN from the patient’s primary care physician detailing the history of GERD in the patient. You would use the ICD-10 diagnostic code Z87.10, personal history other diseases of the digestive system, as part of the diagnosis.

If you’ve provided an LMN, put the code PWKPYBM into box 19 on a CMS 1500 claim form. If a medical doctor has provided an LMN, put the code PWKOZBM in box 19. If you have two letters, or if you consulted the primary care physician to compose your own letter, you may use both codes. Remember, the quality of your clinical notes and your LMNs will determine whether insurance will cover the procedure.

For bulimia, the process is nearly identical, except that you use the diagnosis code Z86.59, personal history of other mental and behavioral disorders, instead. The process may sound complicated, but with proper training, you’ll find that using medical codes to describe diagnoses soon becomes second nature.

The Dangers of Drug Use – Even the Legal Kind

Many patients need reconstructive treatments as a result of adverse side effects from common medications. For instance, when a child is prescribed tetracycline, it often results in catastrophic damage to his adult teeth. When the damage is structural, medical insurance will cover treatments.

Other patients have dental damage from dry mouth caused by drugs prescribed for medical conditions. Many common treatments for asthma, anxiety, seizures, depression, allergies, high blood pressure, nausea, psychosis, Parkinson’s, heart failure GERD, heart disease, ADHD, acne and pain can result in xerostomia. If a patient presents with tooth damage from a dry mouth, take a complete medical history and look for drugs where xerostomia is a known adverse side effect. The restorative or prosthetic treatments may be covered because they treat a side effect of treatment for a medical condition.

And, of course, many patients with a history of illegal drug use also develop dental problems. If a patient who has used cocaine, crack, speed or methamphetamines presents with dental damage, restoration may be covered if they’ve sought medical treatment for their abuse problems. In these cases it’s especially important to consult with a physician and present a well-documented LMN to the insurer.

Finally, remember that every insurance plan is different. Never begin restorative or prosthetic treatment until you’ve presented your case to the insurer, complete with clinical notes, LMNs, and treatment plans. Once you’ve confirmed the benefits, you can help restore your patient’s smile. And she’ll be smiling all the more, because you’ve helped her afford medically necessary treatment by billing medical insurance.

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