In this example Imagn Billing case you will see how a dental office in Washington successfully billed for bone-grafting, barrier, bone excision with biopsy, and complex incision repair. Our Imagn Billing team processed this claim on 08/5/2020 to Premera insurance the claim was denied, and our team filed the appeal on 10/19/2020 and it was paid on 10/31/2020.
The 40-year-old male patient presented for an emergency appointment with symptoms of jaw pain. Radiographs showed radiolucency surrounding tooth 29-30 with moderate mandible atrophy. Also noted, a .3 cm cyst encompassing 29-31 area.
Proving Medical Necessity
As noted in the provider’s SOAP note:
- Medical Indication for removal of 29-30:
- Severe mandible atrophy caused by .3 cm cyst.
- Medical Indication for BG: Prepare site for future implant placement, maintain healthy bone level to support existing dentition.
- Medical Indications for Membrane: protect bone graft and allow bone to mature uninterrupted.
Billing Medical Insurance
The practice collected all required documentation and clinical SOAP notes. After completing the verification of benefits, it was determined that coverage was available after the deductible is satisfied. Pre-Authorization was required and was completed with approval along with a Gap exception.
Without medical insurance contribution, the practice would be writing off approximately 29% and using of the annual $1000.00 maximum. Medical insurance saved the patient and the practice approximately $1500, whereas dental insurance would be exhausted. The patient also completely satisfied their deductible, so moving forward they will have less out of pocket expenses if a healthcare issue arises.