James Anderson

All-On-Four Cases : Establishing Medical Necessity for Dental Implants

More and more dentists are seeking the option to bill dental implants and, in particular, overdentures. It is important to establish medical necessity for these procedures so, if a covered benefit, you will have no issues seeking reimbursement for your patient.
There are several questions that can be asked to determine medical necessity and help gather the necessary background to choose the most appropriate diagnosis codes:

1. Is the condition due to a traumatic injury?
2. Is there a current or previous infection that resulted in the loss of teeth?
3. Were the teeth lost as a result of other health treatments such as chemotherapy or radiation?
4. Is the patient suffering from loss of function?
5. Does the patient have other health conditions that are exacerbated by the lack of dentition? (Examples could be GERD, diabetes, ulcers or other digestive problems)

If the answer to any of the above questions was yes than your patient may qualify for medical reimbursement for their dental implants. The next step would be to determine medical benefits under the patient’s policy. Ensure by asking for benefits on specific codes.
Ensure you are documenting as much of the patient’s medical reasons and history as possible so that appropriate diagnosis codes can be chosen and applied to the claim. Referrals from the patient’s primary care and gastrointestinal specialist can also be instrumental in filing a well-supported claim. Medical benefits can be an excellent starting point for patients who need extensive dental work to alleviate their medical conditions but are limited by their dental plan.


  • Thank u 4 clarifying!! I went on Google, looking 4 a short list of pre-existing and/ or resulting health conditions, that would qualify the required extensive dental work a ‘medical neccesity’ and as such, covered by insurance.

    • You’re welcome for the clarification, Shelby. We make it our mission to provide you with the most up to date information, so that your patients don’t have to worry about their out of pocket costs.

  • I have no teeth currently and have had HIV for 4 years and I have a brain tumor and spinal canal stenosis with bone loss in the jaw and neck bone and spinabifida, and in vitro lead poisoning. I have no money and no credit much, and need dental implants to eat would I qualify for medical necessity for dental implants?

    • I am so sorry to hear about this. Unfortunately, I am not a doctor. So, I would suggest scheduling a consult with a dentist or doctor who can help give you sound dental and medical advice. We wish you all the best.

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