Rank: New Member
Joined: 2/12/2018(UTC)
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I have a patient who has an existing fixed bridge from 6-8, tooth #6 had fractured and is abscessed. I submitted a pre-certification to Aetna to see if I could get her any coverage at all. It was my understanding that if a tooth was removed due to infection, then it could be covered under the medical policy. I spoke with a rep today who told me today that the extraction was going to be denied because it was a medical benefit and that implants/grafting are not covered benefits under the medical policy. I seem to be running into this with every claim I submit. I cannot figure out what I am doing wrong. How can I best go about getting my patients coverage that have an underlying medical reason behind it??
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Hi tcfd1vldg! Great question. Yes, as you mentioned, we do see many medical insurers offering coverage for services that are generally considered dental in nature, however becomes a medical benefit when a condition such as infection or abscess is present, or if trauma/accidentally injury to natural teeth was involved. I always find it helpful the review the insurer's medical policy regarding the type of procedure I am going to bill to familiarize with their coverage criteria. For example, here is a link to Aetna's medical policy titled "Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans" http://www.aetna.com/cpb/medical/data/1_99/0082.htmlAetna's policy is actually quite detailed in the criteria for different types of dental services that are considered medical in nature, so this is a good policy to be familiar with! Hope this helps!
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