All dental plans, regardless of their type, have limitations on the benefits and policy provisions that, at times, will result in a denial of coverage for verified covered benefits. One of the most common denials from insurance plans is for crowns.
The most accepted justification for a full-coverage crown is a missing tooth structure of 50% or more. The remaining tooth structure cannot support a direct restoration such as amalgam or composite.
The crown service fee can range from $1,000 to $2,000 or more depending on the material used and the geographic area of the practice. Most insurance plans cover crowns at about 50% of the usual, customary, and reasonable (UCR) schedule (minus the deductible) or the agreed-upon preferred provider organization fee schedule up to the calendar year maximum. Crowns are paid with the proper evidence of need and supporting documents.
But what may seem like a straightforward crown claim at first glance can result in a denial. Let's take a look at a common scenario.
Scenario: Patient pain is not enough
In this hypothetical scenario, the tooth is visibly cracked and not separated. It may have extensive existing restorations. Further, the patient is experiencing pain to biting pressure and demonstrating evidence of cracked tooth syndrome. However, missing tooth structures, such as a fractured cusp or broken and fractured restorations, aren't noticeable.
In this scenario, a full-coverage crown is recommended and is performed. Then the insurance plan denies coverage based on a lack of supporting documentation, stating that there was no evidence of decay on the x-ray or a fractured cusp(s).
What happened here? Simply stating on the claim that the tooth suffered from cracked tooth syndrome is not enough for the claim to be paid. The claim must also document that the crown was necessary, with the added factor of testing for the cracked tooth.
A word of caution: A bite stick sometimes isn't enough for substantiating cracked tooth syndrome. Note any tests run by the dentist in the clinical chart.
How to substantiate a crown claim
The clinical notes are crucial for ensuring a claim is paid. Narratives/clinical notes to substantiate a crown claim must include the following elements:
- A list of decayed surfaces: Is there active decay? What surfaces are decayed?
- Existing restorations: What is the condition and size of any existing restorations before prep, if the age is known? If it was a crown, what was the original seat date?
- Tooth condition: What is the condition of the remaining tooth structure? What percentage of the tooth is intact?
- Status of the cusps: Are there any missing cusps or undermined or fractured cusps? (e.g., "DL cusp fractured off.")
- Patient symptoms: What symptoms was the patient experiencing before the crown placement, such as pain to cold?
- Documented cracked tooth syndrome: If you suspect cracked tooth syndrome, how was the tooth tested to arrive at this diagnosis? Was methylene blue dye used? Was a cusp positive to a tooth sleuth device?
- Tooth prognosis: What is the endodontic and periodontal prognosis of the tooth? This aspect is not often mentioned in the denial, but it can make a huge difference in an appeal.
- Reason for the crown: What is the reason for replacing an existing crown, other than the age? Why did it fail?
Attaching supporting documentation to a claim is also a must for getting paid. You'll want to include the following items:
- Radiographs: Include diagnostic-quality radiographs showing the entire tooth, crown to apex, the opposing arch, and bitewing.
- Periodontal charting: Attach six-point periodontal charting that has been completed within the last six months.
- Test results: Identify the diagnostic testing devices used and the readings.
- Photographs: Attach intraoral photos marked with the patient's name and date of birth. Indicate on the photo with a marking pen the location of the crack, fractures, decay, and other evidence.
- Prognosis: Report the long-term prognosis from specialists, especially if the tooth is treated with endodontic or periodontal procedures.
Sample appeal letter
If after following all of the above steps, the claim was denied, the following sample appeal letter may help reverse the denial. Be sure to follow the appeal instructions from the insurance company.
Letterhead (Address and contact information of the practice)
Name and address of the insurance plan's appeals department
Name of contact (if applicable)
Member name ID
Patient name and date of birth or ID number
Dear (Claims appeal department):
This request is on behalf of (name of plan member) to appeal the (plan group name and number) decision to deny (name of service, procedure, or treatment sought), claim No.____ for (name of subscriber or patient).
It is our understanding that (name of dental plan)] is denying coverage on the basis that "(cite dental plan's language in the denial letter)." (Attach denial letter or explanation of benefits.) We believe that (name of service and procedure) is dentally and medically necessary to treat (name of plan member)'s dental condition and that (name of service and procedure) is a covered plan benefit.
We have attached the plan benefit document stating coverage for this procedure. (Attach relevant section from the plan benefits document.) The service provided is not an exclusion of the plan.
The patient is under comprehensive dental care in our practice, and care services are administered as the patient's health dictates. I welcome a conference call to discuss the treatment. Please call (phone number) during (practice hours) and ask for Dr. (name) or email me at (email address).
(Describe the member's dental health condition, why the treatment is medically necessary, and what may happen to the patient's health if care is not provided.)
(If the patient is under the care of a periodontist or other specialist related to the care, attach a document demonstrating that the patient is receiving care to improve their overall dental health and what the prognosis is for long-term success.)
If this information is insufficient for your positive determination, we request a review by a nonpartisan licensed dentist or (specialist).
Thank you for your prompt attention to this matter.
Cc: (People to whom you should consider sending copies of your letter, such as the patient/subscriber and the state insurance commissioner)
The more information you can include to substantiate your claim, the better your chances are of getting paid. Appealing denied insurance claims for crowns can be challenging without submitting clinical documentation and supporting attachments demonstrating the need for the crown(s).
Provide comprehensive supporting information when submitting the first claim to eliminate any chance of having to appeal the claim and thereby delay cash flow.
Estela Vargas, CRDH, is the founder and CEO of Remote Sourcing, a dental insurance billing and revenue recovery service. She is a graduate of Miami Dade College's dental hygiene program. Vargas' extensive background in the clinical arena of dentistry is coupled with her experience as a practice administrator and business executive.
The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.