Covered Dental Procedures – basically anything that falls within your plan’s scope of coverage.
- You may have a really simple plan that only ‘covers’ preventative services (e.g. 1 cleaning and 1 exam, plus 4 bitewing x-rays per year).
- Or, you might have a plan that ‘covers’ basic services (really just pays a portion of, say 80%) for more extensive treatments (e.g. fillings and extractions).
- You might even have a plan that ‘covers’ (again, just pays a portion of, say 50%) for major services (e.g. root canals, crowns, dentures, oral surgery)
Insurance companies sometimes deny coverage for a procedure that would normally be ‘covered’ under your plan, if it is not deemed Medically Necessary. You’d think if your doctor prescribed a treatment or procedure (that wasn’t just cosmetic in nature), it would be considered medically necessary, right? Wrong.
Medically Necessary – this term is extremely hard to define since it varies by the insurance provider, Medicare, and plan, but essentially the term refers to a decision by your plan provider that your treatment, test or procedure is necessary for your health or to treat a diagnosed medical problem. It is often the basis for whether they support or deny ‘coverage’ for services listed in the above categories of basic or major services.
Consider this scenario: You need a procedure to treat a condition in your mouth. Our office specializes in the use of cutting-edge technology to perform the treatment. Your plan may deny coverage, because using that technology to treat your condition is not medically necessary, even if prescribed and highly recommended by your doctor. More simply put, is not the most cost effective, economical, or conservative technique to address a medical condition that you have.
Sometimes the insurance company will request additional supporting documentation, or justification (perhaps other methods of treatment have already been attempted without success and they have to see that evidence). As your dental provider, we wish we knew exactly which services every insurance provider will cover and at exactly what amount (80% or 50%…?). Our office does everything we believe we can to provide good quality care and help you afford it. Whether you have insurance or not, know that we only diagnose and recommend services we feel are needed for your overall health. Your happy and healthy mouth is what drives us!