Treatment for Cosmetic Purposes, or Due to Attrition or Wear

Cosmetic services are services requested by your patient that do not meet criteria outlined in plan benefits for insurance reimbursement. Examples include anterior crowns or veneers used to “straighten”, whiten, close/minimize gaps, or to alter the shape and/or size of teeth with no existing dental decay or fillings. Adding tattoos or jewels are also considered cosmetic and should be reported as a separate, by report, miscellaneous procedure. Cosmetic services are processed as non-covered services and your patient is responsible for the full fee charged by your office with no insurance benefit.

The claim documentation submitted for cosmetic services is reviewed by our dental consultants. If disease or fracture is present, the service is subject to normal plan benefits and limitations, which means Participating Dentists are held to the maximum plan allowance for the procedure code submitted.

When restorations are provided to treat cases of attrition, abrasion, erosion, abfraction or altering occlusion, based on group contract limitations, they are not covered by most dental benefits contracts. These types of restorations are processed as non-covered services and your patient is responsible for your full fee with no insurance benefit.

Indicate the reason for treatment based on the patient’s treatment plan/chart notes. The claim can then be reviewed and considered to deny to full patient responsibility.

To have a claim reviewed for re-consideration, please use our easy online claims appeal form located here: Online Appeals Form