Question

A patient's bridge was denied due to a missing tooth clause. When our patient called the carrier, she was told that her plan would allow for an alternate benefit. When asked what that might be, the phone representative would not tell her. What type of information can we provide to help her receive an alternate benefit?

A missing tooth clause excludes payment for a prosthesis if the tooth being replaced was extracted prior to coverage under the current dental plan. Approximately 25-30 percent of today’s dental plans have a missing tooth clause.

Without seeing the patient’s dental plan, it is impossible to know what alternate benefit is allowed. However, keep in mind that the missing tooth clause only applies to that part of the restoration that replaces the missing tooth. In other words, while the pontic may not be covered, you may be able to obtain coverage for one or more bridge retainers if they require crown coverage, independent of the bridge. As such, bridge narratives should address why full crown coverage was necessary for one or both retainer teeth in addition to why and when the tooth/ teeth was/were extracted.

Also note that many dental plans provide an alternate benefit of a partial if two or more teeth are missing in an arch. This is why dental plans often request radiographs showing both sides of the arch. This can be an unpleasant surprise to a patient that is expecting payment for a bridge or implant.

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