Periodontitis is a chronic disease not uncommon to dentistry. Typically, nonsurgical periodontal therapies 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 benefit reimbursement for scaling and root planing claims such a frustration for dental providers and their offices?1 It comes down to the clinical documentation and requirements for a clinical claim-reviewing dentist (who is not chairside) to see the signs of periodontitis and make the recommendation for benefits to be allowed due to medical necessity.
I am a dentist. Before I hung up my handpiece, I practiced conservative restorative dentistry and was proactively treating early signs of periodontitis. I fought tooth and nail for my patients and for their scaling and root planing benefits reimbursement. I was largely successful due to my attention to detail, desire for meticulous clinical documentation, and type A nature.
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When I sold my practice, I transitioned to the payer market. I was clinically reviewing 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 are looking for as they review claims for scaling and root planing benefit reimbursement. If you, too, have asked the ever-popular question, “How do I get my scaling and root planing claims paid?” I encourage you to read on. I mean, we all want to be 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 an adverse benefit determination, any consultant will tell you this exact same information.
Patient scenario
Let’s say you are in your practice on a typical Monday morning. You see your first new patient of the day. Your standard new-patient examination includes acquisition of a full-mouth series of radiographs, six-point periodontal probing, and complete soft and hard tissue assessment. Your new patient is 48 years old and has not seen a dentist in five years, by patient account, so we all know that it’s probably been much longer than that.
Your hygienist performs a preliminary soft tissue examination, which reveals glossy gingiva with loss of stippling, rolled gingival margins, recession, and staining. The hygienist alerts you of the inflammatory signs as well as the presence of plaque, tenacious calculus, periodontal pocketing, and multisite bleeding. Unsurprisingly, you diagnose your new patient with generalized periodontitis and recommend treatment of scaling and root planing in all four quadrants.
“Necessity not evident”
Treatment is scheduled and completed, and your front office submits the periodontal charting record and radiographs to your new patient’s dental insurance carrier for evaluation for medical necessity. Despite the obvious need for treatment and what appears to be the appropriate diagnosis considering all the information, you still receive an adverse determination in the mail. The explanation of benefits (EOB) language indicates the services on the claim are denied for “necessity not [being] evident.” As a dedicated provider, you appeal the adverse determination, recounting the bleeding, calculus, and pocketing. However, you are not focused on the one thing that really matters: visible bone loss.
Every insurance carrier is different. They review claims differently, select claims to review differently, and have clinical criteria that, while similar, is different from one another. The concern across the industry is that the clinical documentation submitted needs to substantiate a “proof of loss,” true “medical necessity” for the treatment rendered.
This is the US. You can certainly treatment plan as you see clinically fit, but we cannot expect an insurance provider to allocate benefits for all treatment submitted. As dentists, we have an obligation to document both subjective and objective findings and give our assessment and plan of treatment. We need to provide this information from the patient’s medical record to the insurance carrier, so they can determine whether benefits are allowed. This often involves a clinical review of the claim.
The intricacies of bone loss
Plenty of factors are considered during a clinical claim review, but one resounding distinguisher for scaling and root planing claims is the evidence of visible bone loss. Since, visible is a subjective word where what I may see and interpret as bone loss, you may perceive differently, the industry trend has moved toward a requirement of visible radiographic bone loss of 2 mm or more, evaluated as the distance measured from the cementoenamel junction (CEJ) to the crest of bone.
In dental school, I was taught that periodontitis is diagnosed when 4 mm probing depths are measured with bone loss evident on the radiographs, so the “visible bone loss” requirement was not such a surprise to me. But I was never taught how much the bone loss was.
There is a host of scientific literature supporting this exact measurement. A study by Hausmann et al., published in the Journal of Periodontology, asked 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 consistent with no bone loss; and this is just one piece of literature agreeing 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 the analysis of scaling claims will become less subjective. Practices can add similar technology to their workflow, highlighting the areas of bone loss exceeding certain measurements and making the diagnosis more consistent. But what if you are not ready to add AI to your office workflow? This doesn’t mean you can’t keep up with the times without AI.
Tips for navigating the dental insurance landscape
- Make sure your bitewing radiographs capture the osseous crest. We can’t discuss bone levels if we can’t see the bone.
- Submit x-rays that show the bone loss, and if an FMX is not required, send just what you need to demonstrate your case. Periapical radiographs (PAs) are considered for benefit determinations, but because of angulation and foreshortening, some payers are prioritizing bitewing radiographs for bone loss detection over periapical images for the same teeth, in cases such as the premolar or molar areas. The American Academy of Periodontology defines stage I periodontitis as cases of 15% radiographic bone loss, which would be measured over the entire root length.3 This percentage can be estimated by the eye and accurately measured by AI, but due to possible distortion, carriers are homing in on bitewing radiographs and the very parallel position of the x-ray sensor to that of the tooth.
- Send a panoramic as additional information—not the sole radiograph for the claim. We agree that a panoramic radiograph is not the most useful as a diagnostic image for diagnosing periodontitis; however, the distal of your distal molars may be captured on a pano and nowhere else. There are instances where the patient is seen for their hygiene periodic exam, has four bitewing radiographs, and no anterior PAs. A panoramic radiograph could serve as a diagnostic piece of information for evaluating nos. 8, 9, 24, and 25.
- Make sure the images you submit are of diagnostic quality. The method of upload and transfer can change a beautiful, trabeculated image into a blurry, pixelated mess. When no one can see anything, we can’t have any kind of civilized conversation about the case.
Although other factors like calculus on the root surface and bleeding are considered, the deciding factor is the presence of radiographic bone loss of at least 2 mm (some cases vary). There will be cases where a patient will benefit from a nonsurgical periodontal therapy like 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 may develop an awareness of the requirements allowing you an accurate benefits discussion with your patients, avoiding unnecessary surprises down the road. It’s crucial 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 in support of them.
Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.
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. What alveolar crest level on a bite-wing 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. https://www.perio.org/research-science/2017-classification-of-periodontal-and-peri-implant-diseases-and-conditions/
