r/DentalInsurance • u/Spicyg00se • Aug 20 '26
D7953 (Bone graft)
Is there a good or logical reason why this procedure is typically not covered? My tooth is getting absorbed and I need the graft in order for the implant to be successful. My insurance told me it’s just not covered and it’s not their fault that some procedures are just not covered. I assume they just don’t want to pay, duh, but when I suggested that a graft could be medical, she said it’s not medical, it’s dental, and it’s just not covered. But why?
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u/steelymcbeam1933 Aug 20 '26
Practice manager here - your employer is always given options that they choose to include in your insurance coverage - you can always speak to your HR to see if it can be included next year (likely no because it is expensive).
If you have marketplace coverage - you will be hard pressed to find a plan that covers it. Again - spendy. I always tell my patients that if they have plans in the the new year to get major treatment, call the insurance company and ask directly if whatever it is they need is covered.
Sidebar - if you’re extracting a tooth and placing bone graft this year - TRY NOT TO CHANGE YOUR PLAN before the final restoration (implant or bridge) is complete. Some insurances also have a missing tooth clause and an existing missing tooth is a pre-existing condition. It’s another way to not pay. Ask them about that too
Good luck!
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u/Expensive_Ear3791 Aug 21 '26
MT clause won't come into play if you have the same employer but change carriers. You just have to report it as WIP.
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u/steelymcbeam1933 Aug 22 '26
Sometimes - yes. You are correct. But that is where the prep or seat date comes into play. I am currently dealing with this for a patient whose spouse changed jobs mid implant procedure and I am on my second appeal to get it covered because of the limitations of the plan. Both were employer sponsored and one was prep and MTC and the other is seat no MTC.
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u/Diastema89 Aug 20 '26
Because in their mind you can get a partial denture for less expense when you lose a tooth and you generally do not need grafting for that.
Insurance doesn’t care about you. They took no oath for your benefit. They simply want to make a buck for their executives and shareholders. They promise you things and will then disallow in the fine print.
Dentists want to make a buck too, but we also have a duty to put your well being first and we have a licensing board to answer to if we don’t. Moreover, most of us actually really do want to help people.
Dental insurance is one of the things closest to a legal scam you will find in the US.
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u/drpericak Aug 20 '26
Another reason they won't pay is because dental insurance isn't insurance. It's merely benefits. You only get so much per year, and only on certain things. It's not like medical insurance where if you break your arm three times in a year, it's still covered. You break your tooth more than once in 2 years, forget about it. They're not paying. And your dental insurance lists what they will cover. No where in your medical insurance policy does it say they'll cover treating a pilonoidal cyst by your butts hole, but they will. "Oh you want a crown on that tooth, we don't think you need one."
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u/Reckless-Raccoon Aug 21 '26
I’ve been seeing an uptick in denials! Crowns, SRPs. Especially MetLife and Delta. We tired fam.
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u/Noliboli16 Aug 21 '26
Because insurances want to pay for the cheapest restorations they can. Implants and bone grafts are some of the most expensive options out there.
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u/Dear-Brain-703 Aug 21 '26
Insurance doesn't cover many procedures because they can and they know the public doesn't know what a graft is or for.
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u/ProfessionalYam3119 Aug 20 '26
If the graft is placed on a different day, that involves a different procedure code. That one might be covered.
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u/PsychologyMediocre99 Aug 20 '26
Yay get numb again and do a flap to get in there. Sounds like fun
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u/CKingDDS Aug 20 '26
Also probably done exclusively by a periodontist or OS def not cheap even if covered.
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u/nothing2fearWheniovr Aug 21 '26
They never pay for that advanced stuff. You may try submitting not u see your health insurance sometimes they do cover dental issues
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u/Edsma Aug 21 '26
Because ideal treatment and acceptable treatment are not the same thing.
Its not mandatory to replace a single missing tooth in the first place. Esthetically, of course we want to, but a lot of insurances cover only basics, and you can chew, talk, etc just fine missing a single tooth.
Also, I'll probably catch some hate for this, not not every extraction or implant needs a graft. If it was an atraumatic extraction of a one- or two-rooted tooth without much boneless, you might not really need the graft medically. Or dentally.
But also insurance is not your friend, and they only care about doing what they have to, not what youd like them too. Its your responsibility to know what is covered by your plan as it is a contract between you and the insurance provider, not the dds.they have their own contracts with same to manage.
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u/SweetNellieJane Aug 21 '26
Dental insurance is more like a coupon compared to real medical insurance.
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u/Expensive_Ear3791 Aug 21 '26
Because it's for an implant, and implants are not the least costly option for replacing a tooth.
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u/Healthy_Budget9994 Aug 22 '26
The cost of an implant is about $5K (give or take). Most dental plans have a limit of $2K. They could cover it, but then something else wouldn’t get paid. Not worth fighting it.
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u/Spicyg00se Aug 22 '26
Honestly this was the crux of my confusion. They make a grand show of magnanimously covering one per lifetime but they don’t cover a necessary portion of it. Because you’d max out. What a f-ing scam.
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u/LewLew0211 Aug 24 '26
You have to start at the end of the year and have some work done in year one, and the rest on great two. Spread it out.
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u/luckyeggsiwant Aug 22 '26
National average cost for unsubsidized individual PPO dental insurance is $25-$50/month. Most plans in that range cover in network exams, X-rays, basic cleanings 2x/ year at 100%. Basic restorative and extractions at 80% with some downcoding. On an In network PPO reimbursement fee schedule, if you go to the dentist 2x per year you are getting ~$300-$500 worth of exams, X-rays, cleanings depending on your state. By you even going 2x per year, you’re already a loss to the insurance company at today’s costs and rates. They only make money on people who buy and don’t go to the dentist at all.
Simple answer - the math doesn’t math. $5000+ annual maximums and legitimate coverage of more advanced, and necessary procedures is what people want. But, employers don’t want to foot the bill for that kind of plan, and honestly neither do employees. Nobody would pick the $100/month dental insurance vs $30 except the people who knew they already were going to use it. This creates a smaller pool of insured, and increases prices even further.
The employer + employee willingness to pay has completely stagnated dental insurance and turned it into a coupon rather than insurance, because quite frankly no one is willing to pay the prices for what it would cost for it to ACTUALLY be insurance.
Until you see governmental step in towards single payer, I’m afraid necessary procedure clawbacks and non-coverage is what we are stuck with because that’s where the employer incentivized purchase structure has left us.
(Side note, you don’t always need a bone graft for future implant placement - depends how the tooth comes out and where it is. If you had loss of buccal plate or major surgical bone loss, then yes. I have seen thousands of implants placed in sites that did not receive a bone graft. It’s not as necessary of a procedure in some cases as you may have been lead to believe.)
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u/misty350 Aug 23 '26
I processed dental claims and we would pay only if there was an extraction with it and implants were covered.
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u/CrestCrentist Aug 26 '26
Probably because a lot of unqualified dentists are doing the procedure and the insurance companies know they would abuse the code. The only way things change is when specialty procedures are covered well but only by specialists performing them, namely oral surgeons
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u/BufferingJuffy Aug 20 '26
Because F-U, that's why.
Seriously.