How does a dentist prove a treatment is medically necessary?

Your dental provider may send clinical records to your dental insurance company to show why a treatment is needed. Those records help explain the health reason for the care. Your insurance plan then uses its own coverage rules to decide what benefits apply.

What you'll learn in this article:

• What "medically necessary" means and why it separates covered care from cosmetic care

• Which records your provider submits to support a claim

• How insurers evaluate those records and why claims get denied

• What you can do if a claim is denied, including how to appeal

If you're facing a treatment decision and wondering about coverage, talk with an Aspen Dental provider. They can tell you what documentation they plan to submit and why.

What "medically necessary" means

The American Dental Association (ADA) defines medically necessary care as reasonable and appropriate care used to treat a health problem. It can include care needed to control infection, pain or disease or restore important functions such as chewing.¹

A filling may be needed to treat tooth decay. Whitening is usually done to change how teeth look. Medical necessity and insurance coverage are not the same thing. Your plan may have its own rules, limits and exclusions.

Why insurers require proof

Insurance companies can't see your mouth. They rely on the records your dental provider sends. A reviewer uses those records to check that the treatment matches a real health need. Requiring proof also keeps the process fair. Without it, coverage criteria would be hard to apply consistently.

What records your provider submits

Your dental provider puts together a file for your insurer. It may include several types of records.

X-rays

X-rays can give the insurer clinical evidence. The National Institute of Dental and Craniofacial Research (NIDCR) says an X-ray can show bone loss caused by gum disease.¹

Periodontal charting

Dental providers use a small probe to measure the spaces, or pockets, around your teeth. Deeper pockets can be a sign of gum disease.

Medical history

Your dental provider may also review your medical history. The NIDCR says factors such as diabetes and tobacco use can contribute to gum disease.¹

Clinical notes and photos

Dental providers document what they find at your visit. Photos show visible signs of damage or disease. Written notes explain the findings in plain terms.

A narrative letter

For complex treatments, your dental provider may write a short letter. It explains why this treatment is needed and not just preferred.

Treatments that often need documentation

Documentation requirements depend on the treatment and your dental plan. The ADA notes that scaling and root planing claims tend to receive more denials or requests for added information than many other procedures. Plans may ask for records such as periodontal charting or diagnostic X-rays.² Your dental provider can check what your plan asks for before submitting the claim.

How insurers review your claim

The insurer reviews the claim under the rules of your dental plan. It may also review clinical records when more information is needed. Coverage can depend on the treatment, your benefits and other limits in your plan. Missing information can delay a decision or lead the insurer to ask for more records.

What happens when a claim is denied

Start by reading the denial or explanation of benefits to find out why the claim was not paid.

If you or your dental provider think the claim was not handled correctly, ask about the plan's appeal process. The ADA recommends appealing in writing and including information that helps explain why the treatment was recommended.² Follow the instructions and deadlines provided by your insurance plan.

What you can do to help

You play a role in this process.

• Share your full medical history with your provider. Include medications, conditions and symptoms.

• Ask for a written treatment plan before care starts.

• Ask your provider or insurer whether preauthorization or predetermination is required or available before treatment.

• Save copies of all letters and explanation of benefits forms.

If you have questions about what your insurance plan may require, talk with your dental provider before treatment. They can explain what documentation may be submitted and help you understand the next steps if your insurer asks for more information.

How does a dentist prove a treatment is medically necessary? FAQs

Still have questions about dental claims and coverage? These answers address a few common concerns.

Which insurance covers my treatment: dental or medical?

Dental and medical insurance follow different rules. Which plan may cover a service depends on your coverage and why the treatment is being done. Your dental provider and insurance company can help you understand which plan should receive the claim.

Can my dental provider appeal without me?

It depends on your plan. Your dental provider may be able to send records or other information to support an appeal. You may also need to complete forms or contact your insurance company yourself.

Does pre-authorization guarantee payment?

No. The ADA says a preauthorization is not a guarantee of payment. The benefit outlined in a preauthorization is based on your coverage at the time you submitted it, not necessarily your coverage on the date you actually receive care.³

What if my insurer calls a treatment cosmetic, but my provider disagrees?

Your dental provider can explain the clinical reason for the treatment and send supporting information. Ask your insurer how to appeal the decision and what records it needs. If the claim is denied again, ask what appeal options remain.

Sources

¹National Institute of Dental and Craniofacial Research: “Periodontal (Gum) Disease.” https://www.nidcr.nih.gov/health-info/gum-disease 
 
²American Dental Association: "Dental Insurance Frequently Asked Questions." https://www.ada.org/resources/practice/dental-insurance/dental-insurance-resources/dental-insurance-frequently-asked-questions 
 
³American Dental Association: "Pre-Authorizations." https://www.ada.org/resources/practice/dental-insurance/pre-authorizations