Which Dental Procedures Might Medical Insurance Cover?

Understanding Dental vs Medical Insurance Coverage

Dental and medical insurance serve different purposes, but there are situations where medical insurance may cover certain dental procedures. Dental insurance typically covers preventive, basic, and major restorative procedures, using CDT (Current Dental Terminology) codes. Medical insurance, on the other hand, focuses on diagnosing, treating, or preventing medical conditions, using ICD-10 and CPT codes. The key distinction is whether the dental service is medically necessary and related to an underlying health issue, not just oral health.

Common Dental Procedures Eligible for Medical Coverage

Medical insurance may cover dental procedures when they are linked to a medical diagnosis or are necessary for treating a medical condition. Common examples include:

• Surgical extractions (e.g., impacted wisdom teeth causing infection or cysts)
• Biopsies of oral lesions or suspicious growths
• Treatment for oral infections that threaten systemic health
• TMJ (temporomandibular joint) disorder treatments
• Dental procedures related to trauma (e.g., facial injuries from accidents)
• Pre-operative dental clearance for organ transplants, heart surgery, or cancer therapy
• Sleep apnea appliances (oral devices prescribed by a physician)

Coverage depends on the patient’s medical policy, the medical necessity of the procedure, and proper documentation.

Documentation Needed for Medical Insurance Claims

To successfully bill medical insurance for dental procedures, thorough documentation is essential. Dental teams should:

• Obtain a detailed medical history and physician referrals when appropriate.
• Document the medical necessity of the procedure, including symptoms, diagnosis, and impact on overall health.
• Use correct ICD-10 and CPT codes (not just CDT codes) when submitting claims.
• Include clinical notes, radiographs, photos, and pathology reports to support the claim.
• Attach letters of medical necessity from the treating dentist or physician.

Accurate and complete documentation increases the likelihood of claim approval and expedites the revenue cycle.

Examples: TMJ Treatment, Accidents, etc.

Let’s look at a few real-world scenarios:

• TMJ Disorder: A patient with chronic jaw pain and limited movement is diagnosed with TMJ disorder. Medical insurance may cover diagnostic imaging (MRI, CT), physical therapy, and even oral appliances if prescribed for a medical reason.
• Accidents and Trauma: If a patient suffers facial injuries in an accident, medical insurance often covers surgical repair, tooth re-implantation, and related dental procedures as part of trauma care.
• Oral Pathology: Removal and biopsy of suspicious oral lesions are typically covered when there’s concern for cancer or systemic disease.
• Pre-Surgical Dental Clearance: Patients needing organ transplants or cardiac surgery may require dental clearance to reduce infection risk. Medical insurance may cover necessary dental work as part of pre-surgical protocols.

Each case requires careful documentation and proper coding to justify medical necessity.

How to Bill Medical for Dental Procedures

Billing medical insurance for dental procedures involves several best practices:

1. Verify medical benefits before treatment. Contact the patient’s medical insurer to confirm coverage for the planned dental procedure.
2. Gather all required documentation, including medical history, physician referrals, and supporting clinical records.
3. Use the correct codes: Assign ICD-10 codes for diagnoses and CPT codes for procedures. CDT codes may be included for reference but are not used for medical claim adjudication.
4. Submit a clean claim with all supporting documents. Ensure the claim form (typically CMS-1500) is filled out accurately.
5. Track the claim and follow up. Monitor the claim status, respond promptly to requests for additional information, and appeal denials with further documentation if necessary.
6. Post EOBs (Explanation of Benefits) and reconcile AR (Accounts Receivable) to ensure proper payment posting and patient billing.

Dental teams that master these steps can expand patient access to care and improve practice revenue by leveraging medical coverage for qualifying dental procedures.