Has insurance crossed the line?

July 1, 2000
After 33 years of practicing dentistry, I thought that I had heard every conceivable excuse from insurance carriers for denying payment for treatment, but apparently we`re never too old to learn. The following statement was received in our office last week in response from METLife to a predetermination of benefits:

Carl L. Zielonka, DDS

Tampa, Fla.

After 33 years of practicing dentistry, I thought that I had heard every conceivable excuse from insurance carriers for denying payment for treatment, but apparently we`re never too old to learn. The following statement was received in our office last week in response from METLife to a predetermination of benefits:

"Based on the information reviewed by our dental consultants, the prognosis for this service appears very uncertain. Therefore, no benefits can be allowed."

It seems that this insurance company has crossed the line between determining benefits and determining treatment. The standard disclaimer from every insurance carrier was something to the effect that it is not making judgment on the treatment when it denies coverage, but it is only following its coverage guidelines or paying for the least expensive treatment.

Am I now to believe that the next step will be to start denying coverage for complex periodontal therapy because the patient has 8 mm pockets and the outcome is uncertain? Or are severely broken-down teeth to be denied endodontic coverage for the same reason?

On the case I submitted for a pre-estimate, I agree that the final prognosis is uncertain; however, I know that the failure to treat will result in a more complex, more costly, and less favorable prognosis. In addition, this was a secondary coverage, and the primary coverage had already approved payment of the submitted treatment plan.

We need to respond to actions like this, or we will find ourselves in the same position as our physician friends. We know best what our patients need and what treatment is appropriate in varying circumstances. I urge anyone who has received such a response from an insurance carrier to respond to that carrier. Better yet, I urge any young dentist to avoid dealing with insurance companies altogether. We must remain in control of our treatment, despite examples such as this attempt to dictate the way we practice dentistry.

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