Crafting a successful dental insurance appeal

February 11, 2011 7:02 AM

Help me craft a successful dental insurance appeal.

Last year, I was surprised when my dental insurance denied my second routine dental exam of the year. They claimed it was my third exam of the year, classifying the examination done by an oral surgeon earlier in the year as the second. I think this rests on an incorrect reading of the policy as written in the certificate of coverage, and sent them this letter:

The claim for periodic oral evaluation was denied incorrectly under processing policy 962: "The contract provides benefits for this procedure twice in a benefit period." The Certificate of Coverage (2010-01-03000-BB-02) lists "Routine examination (periodic evaluation)" as a covered Class I Benefit for Diagnostic Services, with the limitation "Routine examination is covered twice in a calendar year." This is only the second routine examination I have had in the calendar year, and according to the Certificate of Coverage you should therefore pay the claim.

There may be some confusion because I received an additional evaluation from Dr. H. This was not, however, a routine examination (periodic oral evaluation). This was a "specialist examination performed by a Specialist in an American Dental Association-recognized specialty," which is a separate benefit. Dr. H is an oral surgeon that Dr. B referred me to and the specialist examination was necessary to prepare for oral surgery that Dr. H performed and that he billed to my medical insurance. Accordingly, the December 2010 examination should be covered as my second routine examination of the year.

I finally got their response this week:

Your appeal request dated December, 2010, for the periodic oral evaluation (D0120), provided on December, 2010, by Dr. B has been reviewed. As a result of the review, we are continuing to uphold our initial determination for the following reason:

Your dental benefits through the State of Washington Uniform Dental Plan, group 03000, cover oral evaluations twice in a calendar year. Please refer to your 2010 benefit booklet under Class I Benefits, Diagnostic Services, Limitations. Review of your dental records indicates that you received a periodic oral evaluation [earlier in the year], and a detailed and extensive oral evaluation -- problem focused, (D0160). The detailed and extensive oral evaluation is counted as one of your two oral evaluations per benefit period. Therefore, the periodic oral evaluation you received on December, 2010, exceeded the frequency limitations for oral evaluations, and is not a covered benefit under the provisions of your dental plan.

Consequently, no additional payment can be made for the above-referenced claim.

The letter then goes on to say I can appeal the decision further to the appeals committee. I intend to do this. How can I make this succeed? I feel like the reviewer totally ignored the fact that the second examination was not routine, and was, in fact, a "specialist examination performed by a Specialist in an American Dental Association-recognized specialty." Those are not limited, like "routine examination" is. It seems sneaky to re-class it as "two oral evaluations" instead of "two routine oral examinations" per benefit period in that letter. It also seems like the policy as implemented here, contrary to the written certificate of coverage, is bad for preventive dental health since it discourages policyholders who require any specialist treatment from obtaining a routine dental evaluation and cleaning twice a year. An oral surgeon is not going to clean a patient's teeth during a problem-focused visit.

posted by grouse to Work & Money (2 answers total)

The problem may be the way the oral surgeon coded his procedure. He probably should have coded it as a consult, instead of a examination. The insurance company is not doing much thinking here. They have a set of standard code numbers, tied back to specific procedures and exams. They got 3 code numbers for exams, thus the 3rd one is rejected.

You might go back to the oral surgeon and see if they can rebill the procedure as a consult or whatever they would call it that doesn't look like an exam to the insurance company.
posted by COD at 7:26 AM on February 11, 2011

Response by poster: My dentist said he would write off the second visit, so I didn't end up filing an appeal.
posted by grouse at 9:41 AM on April 9, 2011