In this example Imagn Billing case you will see how a dental office in Florida successfully billed for dental crowns. Our Imagn Billing team processed this claim on 12/4/2020 to Tricare insurance and it was paid on 1/22/2021.
The 56-year-old female patient presented for additional treatment following chemotherapy and radiation. She was referred by the Mayo Clinic and pre-authorization was obtained.
Proving Medical Necessity
As noted in the provider’s SOAP note below:
- Squamous cell carcinoma of tongue
- Chemo & radiation 12/13/07
- Medical induced Xerostomia
- Noted necessity for crowns, removal of caries lesions, srp
CLINICAL SOAP NOTE
-Thursday, December 03, 2020 at 12:10:05 PM
Pt presents for Crown: # 29,30
RMH. No changes
Age of Previous Crown: initial placement
Dx: previous treated RCT
Tx: crowns #29,30
Treatment was reviewed with the patient.
Verbal and written consent obtained.
Topical anesthetic: benzocaine
Local anesthetic: Negative aspiration. infiltration with 1.8cc 2% lidocaine 1:100;000epi
Isolation: cotton rolls
Decay removed and tooth prepped for porcelain crown.
HS GL Desensitizer, Prime and Bond Elect, Fluorocore 2
Prep finalized. Retraction cord packed with viscostat for 2 minutes. Retraction cord
Impression taken with Itero scanner.
Provisional fabricated with TempSpan A2 and cemented using HS Temp Cement.
Excess cement removed. Flossed.
Case sent to Glidewell.
Please fabricate full contour zirconium crown.
Patient tolerated procedure well.
POIG, including warnings about postop sensitivity (hot/cold/pressure sensitivity and
possibility of endo). Explained to patient to be careful when flossing in the area around
the temporary and to avoid sticky foods. In the event the provisional comes out, pt
advised to call the office.
NV: Deliver crown/ IMP for partial (cu-sil)
Dr. John/ Pratt
Billing Medical Insurance
The practice collected all required documentation and clinical SOAP notes. After completing the verification of benefits(link), it was determined that coverage was available after co-insurance is satisfied. Pre-Authorization was obtained with an allowance of 6 visits to be completed by 4/30/2021.
Without medical insurance contribution, the practice would be writing off approximately 38% and using the annual $1500.00 maximum. Medical insurance saved the patient and the practice approximately $2000, whereas dental insurance would have been exhausted. If there are any other issues, the provider has the authorization to move forward until 4/30/21
3 thoughts on “How This Dental Crown Case Was Paid By Medical Insurance”
Laurie, thank you for this article. I am attempting to search for resources for how to successfully code her medical insurance for my 23 year old granddaughter’s extensive dental needs. We have received a treatment plan to have all of her teeth crowned. The total cost is 47460. This treatment plan appears to be the consensus of three dentists. Emily had a bone marrow transplant in 2015. She was hospitalized for 16 months in three separate hospitals. During her hospitalization she had many complications, including the need for open heart surgery, acute respiratory distress and a week on ECMO. When she came home on a ventilator and 52 meds per day. All her teeth had cavities. We dealt with that, cost was 10,000. But the teeth under her repairs continued to deteriorate, due in part to acid reflux. Emily needs a hip replacement and due to Covid has waited a year for surgery. But she can not have surgery until her dental issues are addressed due to ongoing infection. The prosthodontist we have selected has no knowledge of how to code for dental work in Emily’s situation. So I am looking for information, and perhaps a person willing to consult with his office. Given the past 6 years, our financial situation does not allow us to meet this financial challenge alone. Again, thanks for the information.
Hello Ms. Jacobsen, that is horrible! My first question is what insurance does she have…HMO, PPO, EPO? The first thing I would want is a letter from her physician to correlate her medical condition with her oral cavity. From there you would need to contact her medical insurance for preauthorization of the treatment plan. Unless her prosthodontist is open to learning medical billing, you or your granddaughter would need to advocate for the benefit.
I’m an RN who experienced an unfortunate accident while in Spain last November and was seen in the ER. I saw a dentist the next morning due to the ER not doing their due diligence and prolonged the vital teeth saving treatment I needed. I fractured 2 teeth and avulsed 1. I have been trying to get my medical insurance to pay for all dental and endodontist visits due to the nature of the injury and medical necessity. They’ve denied all claims due to “incorrect procedure codes” being used. Is there a way I can convert all of the CDT codes to CPT codes? They will accept a resubmission with CPT codes. Thanks in advance!