Patients and dentists both experience some disappointment when insurance will not cover some procedures. However, it is important to remember that the decision-making about dental health belongs to the patient and the dentist, not a “third party”.
“Frequency limitations” will determine how often a particular service is covered (mentioned in the previous post). In the case of a filling, most insurance plans will limit the number of times it will pay for a filling on a surface of a tooth. Every tooth has 5 surfaces; one faces the front of the mouth, one faces the back, one faces the outside, one faces the inside, the last one is the top of the tooth. Once a surface gets a cavity, and is filled, the insurance company will keep track of that tooth number and the surface the filling covered. If the patient is unlucky enough to get another cavity and need another filling in that tooth, and one of those previously filled surfaces is involved, the insurance will not pay for that surface which was previously involved. It does not matter that a new cavity is present, and posing danger to that tooth. This is where the partnership between the dentist and the patient comes into play; a decision is made about keeping teeth healthy. In this particular case, an additional discussion will take place regarding better preventive practices (more on this in another post). The frequency limits that are most common for fillings are 1 to 2 years.
Dental crowns (caps) and bridges also have frequency limits set by insurance plans. Once a tooth has been crowned (individually or as a part of a bridge), coverage for another crown will not be provided for a number of years. There are times when a patient will get a cavity right at the seam, or margin where the tooth meets the crown. Most times, the cavity develops deep under the crown, and a new crown is needed to save the tooth. However, if the insurance plan paid for a crown too recently, it will deny payment for a new crown, even though it is necessary to save that tooth. Here, again is the importance of the partnership between the dentist and the patient; a decision needs to be made about keeping teeth healthy. In this case also, a discussion will take place regarding better preventive practices. The frequency limits that are most common for crowns/bridges are between 2 to 10 years.
When you experience some disappointment regarding a “denied dental claim” it will be important to remember that you and your dentist are partners in deciding your dental future. After all, what else can impact your life as much regarding your enjoyment of meals, your conversations, your smile and, don’t forget, your kiss!
Stay tuned for more about your insurance.
Roger D. Nishimura DDS, Scott J. Anderson DDS and staff