How to Unravel the Clash of Code D7953
Estela Vargas, CRDH, CEO Remote Sourcing
D7953 bone replacement graft for ridge preservation-per site
At the time of the extraction or implant removal or removal to preserve ridge integrity, a graft is placed at the site. This is clinically indicated in preparation for implant reconstruction or where the alveolar contour is critical to planned prosthetic reconstruction. The limitation in coding nomenclature does not include obtaining graft material. If a membrane is used, it should be reported separately.
Dental teams struggled with timely coding to receive benefits for D7953.
D7953 has a lot of "contract language" and exclusions attached to it. Insurance companies treat it like D2950 (Core Build-up, Including pins), where you need to provide a seat date (of the final prosthetic) before the plan pays for it. We are dealing with implants in this situation, so it’s more complicated.
Due to the “language” of the contract is best to let the insurance company know of long-term plans for the patient.
If the patient has implant benefits and there is a plan to restore the edentulous site with an implant, you'll want to inform the plan by sending the treatment plan and consultation notes with the claim.
If it has already been denied, pre-authorize the implant. Once approved, send that with your appeal, and it will be overturned.
Suppose the patient is going to restore the edentulous site with a bridge or partial denture. In that case, you will need to state the medical necessity for preserving the ridge if the pontic/denture is going to sit there.
Medical Necessity Rationale: Resorption of the alveolar ridge begins post‐extraction or removal of a failing implant immediately. This is more pronounced on the buccal aspect and may lead to a loss of 56% of the residual ridge. Positioning a pontic restoration at a missing tooth site must create aesthetic harmony between the restoration and the alveolar ridge. It also improves the patient's ability to keep the bridge's periodontal health. Most instances require the management of these extraction sites either by preventing tissue loss by ridge preservation techniques or by augmenting the already collapsed tissues by bone augmentation (different CDT code), soft tissue augmentation (different CDT code), or a combination.
The medical necessity for a bridge or denture is very valid. Still, you will need help convincing the plan administrator of that, even with medical necessity, as they will argue it is for aesthetic and not functional reasons. This is when you put the ball in the patient's court. The patient needs to understand the medical necessity of D7953; they can advocate for themselves with their insurance company and appeal it on their end or make a case for Human Resources to make sure it gets paid if it is a self-funded plan.
There is a way to win; it just takes collaboration and effort!
TIP: I sometimes include research supporting the medical necessity of treatment in my appeals. It is tough for an insurance claim reviewer to argue with SCIENCE!
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8283858/
