11.7.14 Issue #661 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Belle DuCharme, CDPMA
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Appeal Letters for Denied Dental Insurance Claims
Part Two: The Sample Appeal Letter

By Belle DuCharme, CDPMA

In part one of this article, I laid out the process of preparing to write an insurance claim appeal letter and collecting the relevant information to get the claim paid. If you enjoy working for free, this is not an activity you will see value in doing. But after doing a few of these, you will realize it is better to give more information on a claim the first time rather than appealing it two, three or more times to get paid.

This is a sample of an appeal letter that resulted in the claim being paid at the maximum allowable; the names of parties involved have been removed. Treatment is for a single abutment bridge (cantilever). Background on this claim includes the first denial as “not a covered benefit under this plan”, the second appeal denied for “consultant review deems tooth has endo and perio involvement”, resulting in the third appeal below:

Dental Insurance Company
Patient: ________ DOB ________ ID ___________
Claim #__________Reference #____

Dear Dental Appeals Consultant,

Per the request of our patient, ______, we are reopening the appeal process for the attached claim with additional documentation. Because of the reason for denial listed on the last EOB issued _____ and because our patient talked to a representative for_______ and was told the claim “should not have been denied” we are asking you to review all of the documents attached to this letter. We have included more information to prove that the treatment was warranted and meets the standard of care necessary to alleviate pain and infection and restore our patient’s bite to function with a long term prognosis for success. Important also is that the treatment is a covered benefit under the patient’s policy.

For clarity I have attached documents to support previous appeals. Since the root canal therapy on ______ our patient has been pain and infection free. For _____ months the tooth has not failed, so with this in mind, please process this claim for payment. To deny it for endodontic reasons is absurd as you can see from the attached post-operative report from the endodontist, ______.

Also for your review is the periodontal charting showing that the bone level around the tooth was good and stable and the patient has responded to periodontal therapy. So to deny the claim for periodontal reasons is also questionable. Please see attached the long term prognosis for the prosthetic from Dr.________.

Our patient feels a huge injustice because you have denied this claim twice. When the patient called you, your representative stated that “it should have been paid”. Please see that this injustice is reversed for our patient, _____.

Best regards,
Insurance Coordinator


The next appeal letter also resulted in payment of the highest allowable maximum:

This third appeal is submitted by the request of patient ___________.

We have received your latest denial of the crowns on teeth number 24 and 25 for our patient, _____.  You have seen the evidence but have denied the claim due to “attrition, wear and bruxism.”

The crowns were necessary due to fracture, washed-out existing restoration and severe craze or fracture lines which cause the teeth to split or break off when eating. Because these particular teeth are incisors, they have to hold and bite through food for the patient to eat. The patient states that she does not suffer from bruxism and the condition of her teeth does not warrant normal wear and tear.

Our patient______ made a special trip to the office to have additional intra-oral photos taken of her teeth to show the new crowns in place and to also show the condition of the adjoining teeth. We want you to consider that the crowned teeth were in worse shape than the adjoining teeth, which Dr.____ has determined will need future treatment.

Since the crowns are standard of care in this situation, I would ask that you review the evidence and give our patient the benefits for these crowns under this policy.

I hope this information helps to get your future denied claims paid. To learn more about how to operate a successful and profitable dental practice, contact McKenzie Management for Professional Dental Business Training in your town or ours.

If you would like more information on McKenzie Management’sTraining Programs  to improve the performance of your team, email training@mckenziemgmt.com

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