<p>DH had an expensive dental procedure (3-surface porcelain inlay) and the dental insurance company substituted an alternate procedure (3-surface composite) at a much lower cost (over $1000 difference). X-rays were provided showing a fracture, and the dentist says that the defect was too large for a composite filling. We appealed and they did not change their decision. We now have the option to file a second appeal, which will be reviewed by an external dentist. </p>
<p>Is there a way to find out if our dentist is correct that the procedure they substituted would not have been appropriate? Are there any published standards that I could reference in an appeal? Should I expect the dentist to write up a justification, beyond the narrative that was submitted with the claim? This dentist is out of network.</p>
<p>Probably too late since the work is already done but maybe next time? My dentist took actual photographs and submitted those along with xrays. I don’t remember what the end result was but I the dentist knew from experience that he would have to really document the condition of the tooth.</p>
<p>Would you want to spend all you time looking into mouths? Yuck! Besides, much of these charges are for the things they order from labs (crowns, etc.) and those are expensive.</p>
<p>This should have been pre-authorized, and if a porcelain something was made there had to have been a mold and a temporary covering. I would refuse to pay the dentist the difference, if you are willing to switch dentists if they refuse to treat you again. Most likely the assistant made an error.</p>
<p>These kinds of things happen more often with dentists who are part of a plan with an employer, which is why I stopped using ones that have pre-defined limits. You have to pay more for care, but the care is better - similar to boutique doctors.</p>
<p>We did not get a pre-authorization. The dentist was paid on the day the procedure was performed. I would not refuse to pay the difference, in any case. But I hope he will help us with fighting this.</p>
<p>I’ve replaced a ton of amalgam fillings and never had a reimbursement issue - my dentist always did pre-authorizations. My dentist also has a Cerac machine so he can do the whole procedure in the office in one visit. That includes most crowns. I’m actually a bit surprised that a three-surface wasn’t done as a crown.</p>
<p>Our dentists always do preauthorization also. Even if we go to a dentist within the network, it isn’t covered at 90% for all services & then there are co-pays & deductibles.
Since much of dentistry isn’t on an emergency basis, it is helpful to have the printed estimate of what is covered and what our expense will be so we can plan for it & consider the options.</p>
<p>It sounds like the procedure your dentist used was preferable but if there was $1,000 difference it also sounds like he is expensive.</p>