Periodontitis is a chronic disease not uncommon in dentistry. Typically, non-surgical periodontal treatments are the first line of treatment for the diagnosis of periodontitis. If the Journal of Dental Research reports that 47.2% of US adults age 30 and older have some form of periodontal disease, then why is insurance reimbursement for scaling and root planing claims so frustrating for dentists and their practices?1 It has to do with clinical documentation and the requirements for a dentist reviewing clinical claims (who is not a guide) to see the signs of periodontitis and make the recommendation for allowable benefits due to medical necessity.
I am a dentist. Before I hung up my hearing aid, I was doing conservative restorative dentistry and proactively treating the early signs of periodontitis. I fought tooth and nail for my patients and reimbursement for the benefits of scaling and root planing. I was largely successful because of my attention to detail, my desire for meticulous clinical documentation, and my type A nature.
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When I sold my practice, I moved into the payer market. I was clinically examining the scaling and root planing claims and my world was turned upside down. There was a glass shattering moment (or several) during my training sessions when I learned what insurance carriers look for as they review claims for root planing escalation and reimbursement. If you’ve also asked the ever-popular question, “How do I pay my scaling and root planing claims?” I encourage you to read. I mean, we all want to get paid for what we do. this is not rocket science. There are no trade secrets, so if you exercise your right to a peer-to-peer discussion about determining adverse benefits, any adviser will tell you exactly the same information.
Patient scenario
Let’s say you’re at your practice on a typical Monday morning. You see your first new patient of the day. Your typical new patient exam includes taking a series of full-mouth x-rays, a six-point periodontal scan, and a complete soft and hard tissue evaluation. Your new patient is 48 years old and hasn’t seen a dentist in five years, according to the patient bill, so we all know it’s probably been a lot longer than that.
Your hygienist performs a preliminary soft tissue exam, which reveals shiny gums with loss of ridges, rolled gingival margins, recession, and staining. The hygienist alerts you to inflammatory signs as well as the presence of plaque, stubborn calculus, periodontal pockets and multisite bleeding. As expected, you diagnose your new patient with generalized periodontitis and recommend scaling and root planing treatment in all four quadrants.
“The necessity is not apparent”
Treatment is planned and completed, and your front desk submits the periodontal chart record and x-rays to your new patient’s dental insurance carrier for medical necessity evaluation. Despite the obvious need for treatment and what appears to be an appropriate diagnosis, considering all the information, you still get a negative decision in the mail. The explanation of benefits (EOB) language indicates that the services on the claim are being denied for “not necessary [being] obvious.” As a dedicated provider, you appeal to the negative designation by citing bleeding, calculus, and pockets. However, you fail to focus on the one thing that really matters: visible bone loss.
Every insurance carrier is different. They review claims differently, select claims for review differently, and have clinical criteria that, while similar, are different from each other. The industry-wide concern is that the clinical documentation submitted must document a “proof of loss,” the actual “medical necessity” for the treatment provided.
This is the USA. You can certainly plan treatment as you see fit clinically, but we cannot expect an insurance provider to allocate benefits for all treatment received. As dentists, we have an obligation to document both subjective and objective findings and provide our assessment and treatment plan. We must provide this information from the patient’s medical record to the insurance carrier so they can determine if benefits are allowed. This often involves a clinical review of the claim.
The complications of bone loss
Many factors are considered during a clinical review of claims, but a resounding distinction for scaling and root planing claims is the evidence visible bone loss. From, visible is a subjective word where what I may see and interpret as bone loss, you may perceive differently, the industry trend has moved towards requiring visible radiographic his bone loss 2 mm or more, calculated as the distance measured from the cementoenamel junction (CEJ) to the apex of the bone.
In dental school, I was taught that periodontitis is diagnosed when probing depths of 4 mm are measured with bone loss evident on x-rays, so the requirement of “visible bone loss” was not that surprising to me. But I was never taught how much bone loss was.
There is a wealth of scientific literature that supports this precise measurement. A study by Hausmann et al., published in Periodontology, posed the question, “What alveolar crest level on a BW radiograph represents bone loss?” The study concluded that 0.4 mm to 1.9 mm was compatible with no bone loss. and this is only a part of the literature that agrees on 2 mm or more.2
So what does this mean for you? Insurance companies are incorporating artificial intelligence (AI) to measure these distances so that the analysis of scaled claims becomes less subjective. Practices can add similar technology to their workflow, highlighting areas of bone loss that exceed certain measurements and making diagnosis more consistent. But what if you’re not ready to add AI to your office workflow? That doesn’t mean you can’t keep up with the times without AI.
Tips for navigating the dental insurance landscape
- Make sure the bitewing radiographs capture the bony crest. We cannot discuss bone levels if we cannot see the bone.
- Submit x-rays showing bone loss and if FMX is not required, send exactly what you need to demonstrate your case. Periapical radiographs (PAs) are considered to determine benefit, but because of angulation and premature shortening, some payers prioritize bitewing radiographs to detect bone loss over periapical images for the same teeth, in cases such as premolars or molars spaces. The American Academy of Periodontology defines stage I periodontitis as cases of radiographic bone loss of 15%, which will be measured along the entire length of the root.3 This percentage can be estimated by eye and accurately measured by artificial intelligence, but due to possible distortion, carriers visit bite x-rays and the very parallel position of the x-ray sensor to that of the tooth.
- Send a panoramic as More information— not the only X-ray for the claim. We agree that the panoramic radiograph is not the most useful diagnostic image for the diagnosis of periodontitis. However, the distal of your molars can be captured in a banner and nowhere else. There are cases where the patient visits for a periodic hygiene examination, has four bite x-rays and does not have an anterior PA. A panoramic radiograph could serve as diagnostic information to evaluate nos. 8, 9, 24 and 25.
- Please ensure that the images you submit are of diagnostic quality. The upload and transfer method can turn a beautiful streaky image into a blurry, pixelated mess. When nobody can see anything, we can’t have any kind of civilized conversation about the case.
Although other factors such as calculus on the root surface and bleeding are taken into account, the deciding factor is presence of radiographic bone loss of at least 2 mm (some cases vary). There will be cases where a patient will benefit from a non-surgical periodontal treatment such as scaling and root planing on four or more teeth in a quadrant, but there may not be enough evidence for insurance benefits.
I hope with this knowledge you can become aware of the requirements, allowing you to have an accurate discussion of the benefits with your patients, avoiding unnecessary surprises down the road. It is important to understand that the insurance carrier’s decision is a benefit determination – not a treatment recommendation. The treatment recommendation is clinically yours and yours alone. You are responsible for making the best recommendations for your patients and submitting your diagnostic evidence to support them.
Editor’s Note: This article first appeared on Through the Loupes newsletter, a publication of Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.
bibliographical references
- Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012? 91 (10): 914-920. doi: 10.1177/0022034512457373
- Hausmann E, Allen J, Clerehugh V. Which alveolar ridge level on a bite flap radiograph represents bone loss? J Periodontol. 1991, 62(9):570-572. doi:10.1902/jop.1991.62.9.570
- 2017 Classification of Periodontal and Peri-implant Diseases and Conditions. American Academy of Periodontology. Accessed May 2023.
