Establishing Medical Necessity for Dental Implants for Insurance?

As you may know, the standard of care for lower dentures is a two implant overdenture. I send a narrative and reference the Wickline and Wilson Cases (research this if you are unfamiliar) which transposes liability to the insurance company and they pay. If the patient cannot eat properly and is losing weight with a convential denture, send a Wilson/Wickline letter and they'll get covered.

Dr. Stanton, do you have more information about the Wickline and Wilson Cases?

We have been getting some implants covered by medical insurance. The ICD-9 codes are for disuse atrophy, and alveolar atropy (classified as minimal, moderate, and severe). There is a coding course given by Implant Seminars that is excellent!

Dr. Stanton, in the past we have worked with the patients Md. to include a letter from him/her stating the medical need for implants. I did Google Wickline & Wilson, but only came up with the particular case date. Are you referencing them in your cover letter or is there a specific letter about them. Thanks, J.LoPinto

Dr. Jain, Perhaps they are referring to the following court proceeding? Wickline v State of California, 183 Cal. App. 3d 1064 - California court found public insurer liable for a medically inappropriate decision resulting from defects in the cost containment measures. The court found that the insurer had arbitrarily ignored and unreasonably disregarded an appeal for an extended hospital stay. As a result, the patient suffered amputation of a leg as a result of alleged premature discharge from hospital. Best regards, MK Cantwell

IF A PATIENT NEEDS A HIP REPLACEMENT DO THEY NEED A DENTAL REASON???.IT SEEMS THIRD PARTY FUNDERS LOVE TO CHARGE CLIENTS 2008 SUBSCRIPTION BUT PREFER TO COVER 1965 TREATMENTS. I WOULD OFFER A FREE DENTAL CLEARANCE TO THE FUNDER AND THEN THEY CAN CHEW ON THE INDICATIONS FOR AN INTERVENTION THAT HAS BEEN CONSIDERED THE STANDARD OF CARE FOR THE LAST FEW DECADES AND WHICH IS SUPPORTED BY VOLUMINOUS SCIETIFIC PUBLICATIONS. TELL YOUR PATIENT TO FIRE THE INSURER AND GET DECENT VALUE FOR THEIR CONTRIBUTIONS.

The ADA states that care is medically necessary for the purpose of :controlling or eliminating infection,pain and disease;and restoring facial configuration or funtion necessary for speack, swollowing or chewing. Greetings, KS

I think that you have to read accurately the paper of the insurance of your potential patient. What covers and what not. than see if the subject has difficulties in mastication and pain or rumors at temporo-mandibular joint and others simptoms. at least if the patient needs effectively the substitution of lost dentures and you must too consider her/his professional side.

hello, i think if people can not chew properly they cannot digest there food properly which causes stomach problems down the road. I cannot wear my bottom plate and this is happening to me. So, yes, i consider this a medical problem, and medical should pay for some of this.

I have upper and lower partials for my molars and was wondering if you think the Wickline and Wilson letter would work for me? Im not able to use the partials because they cause alot of pain. my eating habits have definitely changed, I've lost weight and the depression is really starting to weigh on me.

ASKED FOR IMPLANT SUPPORTED DENTURES: have stage four Breast Cancer. My State, California, told me that I had sufficient remaining teeth on my upper Jaw (Maxillary), to support arch integrity on Jan. 16, 2018. All teeth were removed to get a medicine for bone Mets. I do have 8 teeth only on the lower Jaw. All teeth were removed on February 14, 2017, a year and two days prior. 2 Doctors wrote four letters. An Oncologist and the primary care doctor of over 25 years wrote letters of "Medical Necessity" and therefore, not a covered benefit. I cannot wear a denture, convulsive gagging. Because I have enough remaining teeth to support arch integrity, and that, "to keeping denying" wrote a denti-Cal consultant. I can still do chemotherapy, but nothing else for Metastases to the bone. I did use Wickline case but, Denti-cal only gives implants to people under 21 or "Medically Necessary." I have lost 47 pounds while not being able to eat. I cannot find legal help. Anyone know anything let me know, It feels like David and Goliath and Goliath is waiting for me die and hoping for that. I 'd say "facilitating that event."

I am wondering what steps to take to get implants covered by my medical for the following reasons 1. 20 years treatment for Lupus including but not limited to: steroids, medications causing dry mouth 2. Severe Osteoporosis at age 56. I’m on all types of hormone replacement so clearly it’s the steroids taken tomlower disease activity 3. Addison’s Disease which also affects hormones and fluctuate greatly depending on the steroids taken for treatment. So... I have pretty severe bone loss and my gumline is shrinking regardless of my impeccable dental care. I’ve lost 3 molars and have an appt to have 2 more removed in a few weeks!! How am I going to chew after this last removal? Do you think I can get this covered medically?

I have no bottom teeth have denture on top, DENTIST pulled teeth bottom never made dentures,said Medicaid wouldnt cober for 4 yrs HE LIED NOW I LOST TO MUCH BONE FOR DENTURES BEEN IN HOSPITAL MANY TIMES BOWEL OBSTRUCTIONS, SO THERE DEFINITELY MEDICALLY NECESSARY AS PER THE DRS CAN ANYONE HELP IM ON S.S.I MENTAL DISABILITY NOW TOP DENTURE CRACKED IN 1/2 WHAT AM I TO DO ,LAURA