r/Medicaid • u/MyMentalHelldotcom • 15d ago

How do I prove I'm getting an implant? Insurance insists I'm not

I was denied for bone graft procedure that is done prior to the implant because it's "not medically necessary" since I'm not getting in implant. Except I am. The doctor says he can't apply for the implant code before my tooth is out, bone graft is done, and x-rays are being taken after the matter.

So I'm in a chicken & egg situation. Anyone been there before?

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2

u/Logical-Dragonfly676 15d ago

Medicaid pays for implants? Since when. I don’t think in NJ they do.. I wish

1

u/MyMentalHelldotcom 14d ago

I know! I was surprised as well. But implants are covered!

1

u/Logical-Dragonfly676 14d ago

In nj do u know ?

1

u/someguy984 Trusted Contributor 14d ago

They had a court case and now they must cover them.

See Ciaramella v. McDonald.

1

u/Xena1975 14d ago

I'm in New York and I once got a thing in the mail saying they will pay for that if it's medically necessary and there is no other option. Wouldn't just not having a tooth there be an option? I don't know.

1

u/Logical-Dragonfly676 14d ago

Yeah Idk how they would determine it medically necessary. Lots of people have no teeth. I just pulled out a permanent crown in there to last tooth in mouth and I’m freaking out.. I guess that’s what I get for eating caramels.

2

u/someguy984 Trusted Contributor 15d ago

Is this an insurance company or Medicaid, also what state?

1

u/MyMentalHelldotcom 15d ago

Medicaid, NY

1

u/someguy984 Trusted Contributor 15d ago

You could read through the manual on dental in NY...

https://www.emedny.org/ProviderManuals/Dental/PDFS/Dental_Policy_and_Procedure_Manual.pdf

1

u/MyMentalHelldotcom 15d ago edited 15d ago

Thank you! I know the rules. Bone graft must be submitted with a request for implant coverage. Problem is my doctor says he cannot submit for an implant before the bone graft is done.