Hi Guest! Great question. The diagnoses that establish medical necessity for bone grafts and implants do vary from insurer to insurer. However, some diagnoses/situations where we typically see coverage are items like: – Trauma/accidents – of course there are many different diagnostic codes available to represent different traumas and injuries, but a few common ones: K08.411 – Partial loss of teeth due to trauma, class I K08.412 – Partial loss of teeth due to trauma, class II K08.413 – Partial loss of teeth due to trauma, class III K08.414 – Partial loss of teeth due to trauma, class IV K08.419 – Partial loss of teeth due to trauma, unspecified class S02.5XXA – Fracture of tooth (traumatic), initial encounter for closed fracture S02.5XXB – Fracture of tooth (traumatic), initial encounter for open fracture – Tumors/cysts/abscess – again there are many, but here are a few examples: K12.2 – Cellulitis and abscess of mouth K04.6 – Periapical abscess with sinus K04.7 – Periapical abscess without sinus K09.0 – Developmental odontogenic cysts K09.1 – Developmental (nonodontogenic) cysts of oral region K09.8 – Other cysts of oral region, not elsewhere classified K04.8 – Radicular cyst C03.0 – Malignant neoplasm of upper gum C03.1 – Malignant neoplasm of lower gum C03.9 – Malignant neoplasm of gum, unspecified C04.0 – Malignant neoplasm of anterior floor of mouth C04.1 – Malignant neoplasm of lateral floor of mouth C04.8 – Malignant neoplasm of overlapping sites of floor of mouth C04.9 – Malignant neoplasm of floor of mouth, unspecified C05.0 – Malignant neoplasm of hard palate C05.1 – Malignant neoplasm of soft palate C05.8 – Malignant neoplasm of overlapping sites of palate C05.9 – Malignant neoplasm of palate, unspecified C06.1 – Malignant neoplasm of vestibule of mouth For Medicare specifically – their stance on dental services is that “Currently, Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw.” – here is a link to their statement: Hope this helps!
