Disclaimer: Insurance administration and dental billing recommendations, as well as interpretations of the CDT codes, represent the opinions of our experts. For the latest CDT codes and official interpretations, contact the American Dental Association or visit ADA.org. You are responsible for your own use of the CDT Codes, insurance administration, and dental billing.

Cracking the Code: Medical vs. Dental Necessity

Establishing necessity in the dental office can feel like trying to find a second mesiobuccal canal on the last patient of the day on a Monday — challenging, elusive, and quite frustrating. While medical providers, dental providers, and payors all use the same words, they aren’t always speaking the same language. To ensure your practice gets reimbursed accurately and remains audit-proof when submitting medical claims, you need to understand the nuances between medical and dental necessity.

What is medical necessity?

The American Dental Association (ADA) and the American Medical Association (AMA) have distinct lenses through which they view patient care and define medical necessity.

• The ADA defines it as: “The reasonable and appropriate diagnosis, treatment, and follow-up care (including supplies, appliances, and devices) as determined and prescribed by qualified, appropriate health care providers in treating any condition, illness, disease, injury, or birth developmental malformations. Care is medically necessary for the purpose of: controlling or eliminating infection, pain, and disease; and restoring facial configuration or function necessary for speech, swallowing or chewing.”
• The AMA defines it as: “Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider.”

The easiest way to distinguish between medical and dental necessity is to look at the cause of the damage. Medical payors typically make a sharp distinction here:

• Dental in Nature: Teeth damaged by the daily “wear and tear” of chewing and biting. Even if the repair is complex, most medical plans view this as a dental issue.
• Medical in Nature: Teeth damaged by accidental, external trauma. This is where medical insurance typically steps in.

When submitting a medical claim for a procedure, ensure all supporting documentation is included.

Use specific diagnosis codes to define the ‘why’ behind the treatment. Diagnosis coding can be critical for establishing medical necessity during the payor’s initial review. Consider the two diagnosis codes below:

• K03.81 – Cracked tooth: Used for non-traumatic fractures (e.g., biting hard candy). This would typically be considered dentally necessary.
• S02.5XXA – Fracture of tooth (traumatic), initial encounter for closed fracture: Used for injuries from accidents. This would potentially support medical necessity.

Perhaps one of the most common points of confusion is whether or not the dental plan requires submission to a patient’s medical insurance for wisdom tooth extractions. Don’t wait until the claim is denied to find out. During the initial verification of benefits, ask whether the plan requires oral surgery to be billed to the patient’s medical insurance first. Additionally, ask about how the medical payor will accept claims. Some medical plans can be flexible and will allow you to submit dental procedures on a standard ADA claim form, while others require a medical claim form. Knowing this upfront will help avoid confusion and costly mistakes.

Three final tips for receiving appropriate reimbursement.

To keep your revenue cycle healthy and your compliance record clean, follow these three rules:

1. Know the Plan: Every plan is a unique maze of exclusions and limitations. Always contact the plan’s provider service department or review the plan document to understand specific coverages.
2. If It Isn’t Documented, It Didn’t Happen: This is the golden rule of coding. Your clinical notes must clearly state how the treatment affects the patient’s overall medical condition. Legible, accurate, detailed documentation is your best way to establish medical necessity.
3. Code for Reality, Not Reimbursement: Always report the CDT/CPT® and ICD-10-CM code that most accurately describes the service and the patient’s condition. Billing based on “what gets paid” rather than “what you actually did” is considered fraudulent.

At the end of the day, there is no magic button for establishing medical necessity. It is a process of meticulous documentation and understanding payor requirements. To avoid the frustration of delayed claims and appeals, document the exact ‘what’ and ‘why’ of every treatment so your patients receive their benefits promptly, reinforcing their trust and satisfaction with your practice. 

To read our dedicated chapter on medical and dental necessity, see our 2026 Dental Administration with Confidence publication.

Source:

Practice Booster (2026). Dental Administration with Confidence (pp. 202-203). 2025 eAssist Publishing, LLC.