Benefits for restorative procedures

March 1, 2006
Materials for crowns, veneers, inlays, and onlays have been improving during the past decade.

Materials for crowns, veneers, inlays, and onlays have been improving during the past decade. These types of restorations are very popular, despite the fact that dental benefits for some of them are limited.

“Make-over” shows highlight the cosmetic improvements that these types of services provide. Sometimes the enhancements are stunning. Patients are even coming into offices and asking for veneers by brand name! Conversely, some patients are upset about having an inlay or onlay. “Why can’t I just have a filling?” they ask.

What benefits are common for crowns, veneers, inlays, and onlays? How can we talk to patients about the limited nature of insurance payment for these services? What do we tell patients who wonder why they “can’t just have a filling”?

Let’s discuss some common insurance benefits.

Inlays usually are paid by indemnity insurance at a “Least Expensive Alternative Treatment” (LEAT) allowance. A LEAT clause is included in most benefit -plan contracts. It means that the carrier may assign a benefit for a treatment based on the least expensive “appropriate” restoration, regardless of what the dentist recommends or the patient prefers. It is a common cost-control mechanism. For inlays, the patient’s benefit typically is based on a carrier’s reimbursement for an amalgam restoration.

A common reimbursement requirement for onlays stipulates that two or more cusps of a tooth must be involved, with 80 percent or more of the incline on each cusp affected. (Some carriers require that all cusps be involved.) When the decay or fracture involvement of a tooth would be sufficient to necessitate and generate a benefit for a crown, then an onlay may be a benefit. When inlays or onlays are recommended for persons with special needs, a preauthorization may help the patient receive the best possible benefit. A narrative should be included giving the reasons why an inlay or onlay is preferred, and pertinent documentation should be sent as an attachment.

For example:

A patient’s documented allergy to mercury, with allergy test results attached to the claim.

Documentation of periodontal conditions that mandate supragingival margins.

Veneers may be covered if they are required to restore decayed surfaces or they are a replacement for existing defective restorations. An intraoral photo can be helpful. Veneers placed for cosmetic reasons only are typically not a benefit.

Crowns are covered by many plans. Most carriers reimburse patients for anterior, bicuspid, and maxillary first-molar, “tooth-colored” crowns. Other molars are reimbursed at a “metal” allotment. Crowns may be a benefit if there are at least four or more surfaces of decay, fractures, broken cusps, previous endo, or other problems. This should be noted on the claim form.

Talking to patients

Staff members can explain to patients that dental plans cover a portion of the costs of dental treatment, but dental insurance is not like medical insurance. Most contracts pay a minimum, regardless of what services might be recommended. Despite this, any amount covered reduces what patients have to pay out-of-pocket. It helps! When staff members approach benefits in a positive way, patients often react a little more positively. After all, $1,000 a year to use toward dental treatment is a big improvement over $0 to use toward dental treatment!

When patients ask why they cannot “just have a filling,” the staff can discuss situations where a “filling” is appropriate, and situations where it is not. One good explanation is that for a “filling” to work, there must be enough of the natural tooth left to support the restoration.

Patients also may ask why they should have services performed for which insurance will not fully pay. It should be pointed out that benefits should not be a person’s only consideration when making health decisions. Patients owe it to themselves to carefully consider the advice the dentist is giving. People who have lost their teeth often say they would pay any amount of money to get them back (Go to to read my new brochure, “Crowns, Veneers, Inlays, and Onlays”).

Carol Tekavec, CDA, RDH, is the author of the “Dental Insurance Coding Handbook-CDT 2005.” She is the designer of a dental chart and is a lecturer with the ADA Seminar Series. Contact her by phone at (800) 548-2164 or visit her Web site at, where you may also read her patient brochure, “My Insurance Covers This ... Right?”

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