Insurance Connection
came as a direct result of a UCD pilot program performed in another state , in which UCD found that an alarming percentage of general dentists performed scaling and root planing in cases with no radiographic evidence of bone loss and , therefore , according to UCD ’ s new policy , no periodontal disease . In some postmeeting emails , UCD representatives clarified the radiographic evidence to be bone loss 1mm apical to the CEJ . Due to the fact that crestal bone is generally 1.5 mm apical to the CEJ in healthy mouths , further communication may be necessary in regards to this policy if dentists begin experiencing denials for lack of radiographic evidence of bone loss . The portion of UCD ’ s edited answer , listed above , which credits the AAP ’ s insurance consultant and president with the notion that periodontitis can only be diagnosed with radiographic evidence of bone loss was not independently corroborated . The Dental Benefits Committee attempted to corroborate this information with the AAP members mentioned by UCD representatives , but no calls or emails were returned from the AAP regarding the issue .
Some of the committee members were concerned with this policy , because radiographic “ proof ” of bone loss is a very objective criteria for a multifactorial and complicated diagnosis / staging . Many periodontal residents have commented on their very early academic experience with the inaccuracy of radiographs alone in diagnosing periodontitis . Therefore , to use the lack of that inaccurate information alone to rule out periodontitis seems potentially inconsistent . Ultimately , some committee members are concerned that the need for radiographic evidence of bone loss is overly restrictive by the parameters developed and published by the AAP . The AAP parameter for chronic periodontitis with slight to moderate loss of periodontal support ( http :// www . perio . org / resources-products / pdf / 853 . pdf ) clearly states that patients may have associated radiographic evidence of bone loss . Contrast this possibility of radiographic bone loss to the AAP parameter for care for chronic periodontitis with advanced loss of periodontal support ( http :// www . perio . org / resourcesproducts / pdf / 856 . pdf ). This more advanced disease parameter clearly states that radiographic evidence of bone loss is present .
The question is not whether bone loss exists in early chronic periodontitis . It clearly does . The question is , with differing degrees of clarity , resolution and contrast in different radiographic systems , does that bone loss have to be present radiographically in order for periodontitis to be diagnosable ? With UCD and many of the major insurers mandating that bone loss be radiographically evident for a benefit to be allowed , some members of the committee were concerned that many patients with early periodontitis would be left to pay for their treatment out of pocket or financially forced to allow the condition to worsen before having it treated appropriately . The committee is interested in making sure that patients with early chronic periodontitis not be denied an insurance benefit for a disease that cannot be accurately diagnosed or ruled out with radiographs alone . Interesting to note is that UCD is not the only insurance company with this criteria . UCD was , however , the only company of the major insurers that actually agreed to meet with us . For that , we are grateful to them for being able to even have this dialogue and are certain that they are equally concerned that their subscribers get timely and appropriate treatment for their disease . The committee also recognizes that performing scaling and root planing in areas where no bone loss exists , can often times lead to damage of the periodontal tissues resulting in bone loss that didn ’ t exist pre-operatively . Therefore , it is imperative that we , dental professionals who diagnose and deliver the care and insurance companies who often times determine benefit allowance , agree upon a standard of care that includes academically supported and professionally accepted criteria for the diagnosis of and treatment for this earliest stage of periodontitis .
Please contact PDA if UCD is denying your claims for scaling and root planing for lack of providing sufficient radiographic evidence of bone loss . We would like to track the number of denied claims as we continue our dialogue with UCD .
Question : What is the clinical rationale for UCD ’ s policy relating to Code D0140 that suggests dentists should render treatment without first performing an examination and diagnosis ? This insurance policy is inconsistent with the State Board of Dentistry requirements found under the definitions of direct and general supervision .
Answer : UCD believed the committee ’ s question is incorrect . This used to be UCD ’ s policy but it changed three years ago . UCD now allows a benefit for an examination , diagnosis and treatment given on the same day to patients who come in unexpectedly . If this happens two or more times in one year , UCD will consider the second and successive occurrences as “ uncovered billable ” procedure / s and patients may be charged according to contract allowances .
Question : What is the clinical rationale behind making D0460 a non-integral procedure if performed on a day different than the day that the root canal procedure is performed ? How does UCD determine what is
12 November / December 2010 • Pennsylvania Dental Journal