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Top 5 Dental Procedures Denied by Payers and Why

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Millions of patients get their dental claims denied each year. The reasons for these denials vary, but one of the most common is lack of coverage. Furthermore, many payers fail to cover procedures deemed “unnecessary” or “experimental,” even though these procedures may be necessary for the patient’s overall health.

In this article, we’ve highlighted the top five dental procedures that most payers deny and their reasons for doing so:

1. Dental Sealants

Dental sealants are a preventive measure that can help protect teeth from decay. However, despite their effectiveness, many payers deny coverage for this dental procedure.

While sealants can provide long-term protection from decay, many payers view the procedure as elective or non-essential. As a result, they may not be willing to cover the costs associated with treatment. 

Another reason why payers deny coverage for dental sealants is because of the cost. Sealants can be expensive, and many payers feel that the cost is not justified when other preventive measures are available. This is why some payers will only cover sealants for children, as they are more likely to benefit from the long-term effects of the procedure. 

Finally, some payers may deny coverage for dental sealants because of the lack of evidence-based research that demonstrates the effectiveness of the procedure. While sealants have been shown to be an effective way to prevent decay, some payers may not be convinced of their long-term benefits. 

Despite the reasons why payers deny coverage for dental sealants, dentists can still provide the procedure to patients. One way to do this is to contact the payer and explain why the procedure is necessary. In some cases, the payer may be willing to reconsider their decision and provide coverage. Alternatively, dentists can also work with patients to find other ways to cover the cost of the procedure. 

2. Orthodontics

When it comes to orthodontic treatment, many payers deny coverage due to the cost and complexity of the procedure. Orthodontic treatment is often considered cosmetic in nature, and many insurance plans do not provide coverage for it. Additionally, orthodontic procedures are considered elective and not medically necessary, meaning they are not covered by most insurance plans. 

In some cases, payers may also deny coverage because of the age of the patient. For example, if a patient is over the age of 18 and is seeking orthodontic treatment, many insurance plans will not cover the procedure as it is considered a cosmetic procedure. 

Payers may also deny coverage because of the length of the treatment. Orthodontic treatment often takes several months or even years to complete, and insurance plans may not be willing to cover the entire cost of the treatment. 

Finally, payers may deny coverage because of the pre-existing condition of the patient. If the patient has an underlying medical condition, such as a cleft lip or palate, then the insurance plan may not cover the orthodontic treatment. 

3. Implants

Payers, including health insurance companies, often deny dental implants as a dental procedure due to the high cost associated with the procedure. Dental implants are considered a major restorative procedure and can cost thousands of dollars.

In addition to the cost of the implant itself, there are other associated costs, such as the placement of the implant and the restoration of the tooth. These costs can add up quickly, making the procedure unaffordable for many people. Additionally, insurance companies may view dental implants as an elective procedure, meaning it is not medically necessary and therefore not covered.

Finally, insurance companies may deny implants due to the risk of complications associated with the procedure. While implants are generally considered safe, there is always a risk of infection or other complications. Insurance companies may view this risk as too great to cover the procedure, leading them to deny the claim.

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4. Bridges

Bridges are a type of dental treatment used to replace a tooth that has been lost or damaged. The procedure involves attaching an artificial tooth to the adjacent teeth in order to fill the gap. While bridges can be a cost-effective and long-term solution to missing or damaged teeth, they can also be expensive. 

Payers can deny bridges as a dental procedure for a variety of reasons. In most cases, it’s because the cost of the procedure is too high. Depending on the type of bridge and the materials used, the cost of the procedure can range from several hundred to several thousand dollars. As a result, payers may decide that the cost of the procedure is too high and deny coverage. 

In some cases, payers may deny coverage for bridges because the patient does not meet the criteria for coverage. For example, some policies may require that a patient have a certain amount of healthy teeth to be eligible for the procedure. In addition, some policies may have a maximum dollar amount that they will cover for the procedure. 

5. Root Canals

Root canals are a common dental procedure that can help restore an infected or damaged tooth. However, they can be expensive and may not be covered by all insurance plans. This means that payers may deny coverage for root canals, leaving patients with a hefty bill. 

There are several reasons why payers may choose to deny coverage for root canals. One of the most common reasons is that the procedure is not deemed “medically necessary.” Payers may determine that a root canal is not necessary for a patient’s oral health or that the patient can manage their dental issue with a less invasive and expensive treatment. 

In addition, payers may also deny coverage for root canals if the patient has not met their deductible. If the cost of the root canal exceeds the amount of the deductible, the patient may be responsible for the full cost of the procedure.

Finally, payers may also deny coverage if the patient has exceeded their annual maximum benefit amount. If the cost of the root canal puts them over the maximum amount, they may be responsible for the full cost of the procedure. 

How a Medical Billing Clearinghouse Can Minimize Dental Claims Denials 

Every year, dental practices lose thousands of dollars due to dental claims denials. Besides the financial implications, there are several other ways denied dental claims impact dental practices, including loss of patients’ trust, employee burnout, and organizational conflicts. 

Fortunately, there is a way to save your practice from the hassle and frustration of dental claims denials: using a medical billing clearinghouse. This is where Apex EDI comes in.

Apex EDI is a medical billing clearinghouse that can help simplify and automate the claims submission process. By utilizing our services, your dental practice can avoid the delays associated with paper-based claims processing and ensure that claims are submitted correctly. The platform is designed to reduce illegal dental billing mistakes and increase the accuracy of claims submission. The EDI solution also helps speed up claims processing, so you can get paid faster.

Apex EDI also helps manage rejections. When claims are rejected, the platform notifies your practice and provides information about the reason for the rejection. This allows your practice to resolve the issue quickly and resubmit the claim for payment. In addition, the platform provides detailed analytics and reporting to help your practice identify and address any issues that may be causing denials. Schedule a demo to find out more about Apex EDI and how it can streamline your billing process.



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