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Dentition Damage Covered by Medical Insurance

By:  Christine Taxin
Published:  April 5th, 2016

Generally, restorative dental treatments are not covered by a patient’s medical policy, except in cases of traumatic injury. However, if the patient exhibits oral side effects from a medical condition, an over-the-counter drug, a prescription medication or an illegal drug, then there is a good case to be made for "medical necessity," resulting in payment of medical benefits for treatment of the resultant damage. This, of course, varies from policy to policy, but many plans do in fact cover the restorative and prosthetic reconstruction of teeth necessary to repair this type of damage.

A general understanding of the diseases, medical conditions and side effects that can result in damage to tooth structure is essential in determining which dental treatments are eligible for coverage under existing medical plans, along with their appropriate coding.

Medical Conditions Damaging to the Teeth

Damage to dental structures, from simple erosion of the enamel to deeper injury involving the dentin and pulp, can be caused by several conditions. Examples include:

  1. Gastroesophageal reflux disease (GERD) and bulimia
  2. Xerostomia
  3. Side effects of medication prescribed during tooth formation
  4. Sjögren’s syndrome and dry mouth
  5. Side effect of methadone use
  6. Recreational drug use

Coding Dental Damage

Addressing these conditions one by one, along with the coding required to bill medical plans for the corresponding dental treatment, helps to explain how and why medical benefits can be used to pay for the restoration of teeth in cases of medical necessity.

Note that the International Classification of Diseases (ICD10) establishes the diagnosis codes that are applied in these situations, which are used to classify a wide variety of signs, symptoms, complaints, external causes of injury or disease, and other factors determining an individual’s health condition.

Along with a CMS 1500 (red form if you are doing by hand) medical claim form, clinical progress notes or a letter of medical necessity from the dentist should be submitted to the insurance company for reimbursement. A medical necessity letter from the treating physician, confirming diagnosis of an applicable medical condition or history of drug use, strengthens the case for medical necessity and is highly recommended for claim submission as well. In Box 19 of the claim form, use code PWKPYBM to indicate documentation from the treating dentist and PWKOZBM to indicate documentation from a physician. If you are able to call physician and get his diagnosis all the better. Put both into one and use both codes

GERD AND BULIMIA

GERD, or acid reflux disease, is a systemic problem typically associated with the regurgitation of stomach acids up into the esophagus and, frequently, into the mouth. Bulimia is a condition in which the patient is driven to self-induce vomiting by a psychological or mental disorder, such as a severe fear of weight gain or body dysmorphic disorder. In both conditions, the teeth are repeatedly exposed to stomach acids that can cause an "etching," of the tooth structures over time, leading to eventual breakdown of the enamel, which, when left untreated, can progress into the dentin. A personal history of GERD would be reported with the diagnosis Z87.19 Personal history of other diseases of the digestive system   Bulimia would be reported Z86.59 Personal history of other mental and behavioral disorders

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