DENTAL REVIEW, P.C.
(“NADENT”) Copyright 1991, 2002, 2013, 2015
Dental trauma continues to be a major area of cost and concern among claim adjusters. The biggest issue pertains to teeth that were alleged to have broken or fractured due to trauma, but were actually broken down due entirely, or primarily, to pre-existing conditions. Upon review by a dental professional it is frequently found that these conditions were not caused by, or aggravated by, the incident claimed to have caused the condition, but are due to decay, wear and tear, or other factors such as advanced bone loss due to periodontal disease, etc.
In other words, many claims for broken teeth may be classified as false, exaggerated, or even fraudulent, but some are merely a misperception or misunderstanding on the part of the claimant. The cost of these claims may begin at $400 to $2,500 (i.e., root canal, post, and crown) and many are much more costly, some as much as $25,000 or more (those that include implants, bridges, treatment of temporomandibular joint disorder (TMD), etc.,)
Thus, it is important to have all dental injury claims reviewed for: 1) causal relationship to the incident, 2) appropriateness of treatment, 3) if treatment is betterment over prior conditions, and
4) appropriateness and reasonableness of fees.
NADENT consultants also review TMD claims. While these types of claims have diminished in recent years and are not as much of an issue as they were years ago, some of the credit for this goes to NADENT’s TMD experts reviewing large numbers of this type of claim over the past many years.
NADENT's TMD consultants incorporate the most up-to-date clinical research into the claim review process, providing recommendations that are consistent with the most current scientific findings in the field of dentistry. By submitting these claims to NADENT for review, claim adjusters can be more certain that inappropriate submissions for TMD will be detected and identified.
Technical language in dentist’s records, submitted as part of dental claims, is another common reason many of our clients submit their claims to NADENT for review. Our consultants convey their opinions in reports that are clearly stated and more easily understood by people with no dental background.
NADENT consultants review each claim objectively, to determine if the claim is fully legitimate and limited to treatment that is causally related to the incident, or if the treatment proposed includes items that are for conditions unrelated to the incident reported. For these latter claims, a substantial savings results by restricting payments to only those charges which are truly related to the incident. Charges for treatment of pre-existing, unrelated conditions are to remain the claimant’s responsibility to pay.
It is not uncommon for a claimant to submit a Treatment Plan from his or her dentist which includes all the patient’s conditions in need of treatment. Whenever treatment related to a claimed injury is not clearly differentiated from what is unrelated, it is nearly impossible for the claim adjuster to determine the amount payable without calling upon NADENT for help.
DENTAL REVIEW SERVICE
NADENT provides extensive dental consulting services in all 50 states through a network of licensed dental professionals representing most dental specialties. Many major insurance carriers have selected NADENT as their ‘go to’ firm to provide a review of most dental claims.
DENTAL TRAUMA REVIEW CRITERIA
The following situations would suggest a need for dental consultation:
• An allegation of dental trauma, with no mention or confirmation of any facial or dental injuries, and no head or neck x-rays taken or submitted
• Cases in which dental treatment exceeds $400
• Cases in which the claim - regardless of amount - appears to be questionable
• Alleged injuries to teeth spaced far apart in the mouth,
i.e., T#3, 14, 19, 30, etc. (Refer to Tooth Chart – page 9)
• A delay in seeking dental treatment
• Allegations as to the necessity of lifelong dental treatment
• Allegations of TMD
• Requests for orthodontic treatment
• Indication of a need for extensive periodontal therapy
TEMPOROMANDIBULAR DISORDERS (TMD)
The following is a position paper prepared by NADENT, regarding claims for Temporo-mandibular Disorders (TMD).
Insurance companies that write medical and/or dental benefit plans for trauma often receive claims from physicians or dentists who treat "TMJ" (temporomandibular joint) Disorders, or “TMD”. There has been some confusion as to how these claims should be handled. It is common for this complex disorder to be covered under either medical or dental plans, and it may be abused in certain trauma claims.
The following represents our current recommendations for claims processing based on guidelines for diagnosis and treatment developed by recognized leaders in the treatment of TMD.
There can be several disorders related to the TMJ area, the region where the lower jaw functions and moves from. These disorders can involve the associated muscles, bones, and ligaments in the craniofacial area. It is well known in general, that the etiologies associated with TMJ disorders are highly controversial and often inconsistent in a given population.
The etiologies of TMJ disorders are most likely multi-factorial and often chronic in nature. There are several risk factors believed to contribute to TMD including systemic conditions, parafunctional habits like grinding, and trauma to name a few. It is primarily the dental profession that diagnoses and treats these disorders.
As in the treatment of injuries and disorders of other joints where splinting and bracing are required, the treatment of the TMJ complex frequently requires the use of an occlusal splint.
A splint is used to support and stabilize the jaw joint, relax the associated ligaments and facial muscles, and decrease inflammation. In this way, these splints are truly orthopedic in nature.
NADENT recommends that insurance companies adopt the following guidelines for the handling of insurance claims for any of the several medical disorders known broadly as "TMD" or craniomandibular disorders.
1. Benefits should be considered under medical plans for diagnostic procedures related to craniomandibular (TMD) disorders, provided that the attending dentist includes at a minimum, the following:
A. Complete medical and dental history and a complete history of the pain dysfunction complaint.
B. Complete clinical examination appropriate to the complaint.
C. Minimum x-rays necessary to make treatment choices.
D. Diagnostic study models may be indicated.
2. When requesting pre-determination of benefits:
A. The diagnosis of the disorder(s) must be specific and definable by the appropriate ICD-9 code(s). Possible or probable diagnosis should be provided with appropriate ICD-9 codes.
B. An itemized treatment plan with appropriate CPT codes must be included.
TREATMENT OF TEMPOROMANDIBULAR DISORDERS
Conservative therapy is considered the first line of treatment for TMD’s and often combines the use of an occlusal splint with behavior modification, physical therapy, and possible use of non-steroidal anti-inflammatory medications and/or muscle relaxants. This treatment is designed to relieve symptoms, reduce inflammation, encourage healing, promote behavior conducive with healing the TMJ, and to achieve patient comfort. Other treatment modalities appropriate to conservative therapy include the following procedures:
• Soft chew diet
• Moist heat and/or ice
• Ultra-sound, transcutaneous nerve stimulation (TENS)
In many case, the insurance company's responsibility often ends with completion of conservative therapy. This must be determined in each individual case by a NADENT consultant. Some individuals with TMD’s may require treatment beyond conservative therapy. Such disorders may include certain disc displacement problems, bony fibrous ankylosis of the joint, or fractured jaws. Additional therapy may be justified only if certain criteria are met. Additional treatment may include one of the following:
1. Occlusal adjustment or equilibration of the teeth
2. Orthodontic treatment
3. Orthognathic surgery
5. Prosthodontic treatment or a full-mouth rehabilitation
Due to the complex nature of these disorders and the variety of treatment modalities that are currently employed, it is advisable to refer these claims to NADENT. It should also be noted that many post-trauma facial or joint pains may be unrelated to the TMJ.