Belle DuCharme

CDPMA, Dental Training Consultant

Worst Claim Story- February 2019

We don’t cover erosion and “wear and tear,” said the claims representative on a call to appeal the denial of the claim for our patient.  The teeth in question were #8, 9, 10 that were treated with full porcelain veneers. Before treatment, the teeth had MDFI composite restorations, 8 years old and washing and fracturing out exposing dentin and some recurrent decay.   The radiographs showed all healthy apex, however, the teeth looked intact and didn’t demonstrate at all what was necessary to restore. Prior to the veneers, it was not only aesthetically displeasing but clinically needed to be treated and not by new fillings.  The tooth structure was not fractured off but was unsound with severe thinning and chipping. What we failed to do was to take intra-oral photos. This would have demonstrated the clinical need for the veneers. The insurance company denied because of lack of supporting evidence.

Searching through the clinical chart, I was able to locate some radiographs sent by a previous dentist 8 years prior.  This did show some decay prior to the composite restorations. Then I saw the photograph of the smiling patient in the chart.  We always took a photo to place on the computer chart for identification purposes. This photo saved the day because it showed the patient in full smile with the yellowed, fracturing out, recurrent decay toothy smile.  The claim was paid after submitting the photo and previous x-rays. 

Dental Billing Tips and News for Pros; Edition #132


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