Dental vs Medical Criteria

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
July 12th, 2016

Medical Necessity is the key to coverage under a medical plan for a dental procedure, be sure you review what is required medical necessary under each individual policy, and which procedures need pre-certification, below are some reasons a medical policy may cover.  

• Exams, radiographs and consultations for medically necessary dental procedures
• Many oral surgical procedures
• Excisions
• Biopsies
• Reconstruction due to trauma or genetics
• Endodontics due to trauma or a medical condition
• TMD procedures including treatment of myofascial pain conditions
• Emergency treatment of oral inflammation
• Non-surgical sleep apnea treatment
• Patients with medical conditions such as diabetes, heart disease,pregnancy, hormonal conditions, Parkinson’s disease, Alzheimer’s disease
• Dental treatment required due to patients needing radiation treat-ment
• Implants
   Loss of teeth due to trauma
   Loss of teeth due to systemic conditions (e.g. tumors, cysts,radiation therapy, cancer, genetics)
   Bone atrophy that results in dentures that won’t seat correctly, resulting in difficulties with chewing and getting good nutrition
• Patients needing a dental clearance prior to surgery

Keep in mind when using CPT codes - (Medical procedure codes), you need to file a claim with a CMS-1500 which required by most insurance payers, the CMS-1500 is different from the dental form you are used to.  Find-A-Code has instruction's on how to fill out a CMS-1500 claim form under the "Info" tab. If the medical claim is filled out incorrectly it will likely result in a denied claim.


Dental vs Medical Criteria. (2016, July 12). Find-A-Code Articles. Retrieved from

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