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Anyone Successfully Appealed a Downgraded Dental Insurance Claim?

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rated:
I have a rear tooth with a cavity on the side of the tooth, with an old amalgam(metal) filling on the top of the tooth.  As a result, I need a porcelain inlay (I trust the dentist).  The negotiated rate on this is about $600, but my insurance would downgrade this to an amalgam filling an reimburse about $40.  My reimbursement for this type of treatment is 80%.  

I know dental insurance is a bit of a joke, but I get it for free with my employer.  However, it seems crazy they could downgrade to an amalgam filling if the dentist is saying my tooth doesn't have the structural support for another filling.  

Anyone successfully appealed this type of downgrade and have any tips/tricks?

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rated:
1) Rear teeth don't need Porcelain they are in the rear after all.
2) Dentists are like car repair dealers, they like to push the higher level repair so it lasts longer, but the insurance doesn't do 'preventative stuff like that'.

Ex : My dentist is pushing me to have 'laser' treatment and even gave me a brochure that talks about how it's better and how a study shows it's better. When I look up the study at the end it says, laser appears can be as effective as traditional treatment. I was like huh, it's not better? It costs $100 more.

So after all that, to appeal you need your dentist to contact the insurance company, it was your dentist who gave a 'not so good explanation' to the insurance company to cause a denial after all.

rated:
forbin4040 said:   1) Rear teeth don't need Porcelain they are in the rear after all.
2) Dentists are like car repair dealers, they like to push the higher level repair so it lasts longer, but the insurance doesn't do 'preventative stuff like that'.

Ex : My dentist is pushing me to have 'laser' treatment and even gave me a brochure that talks about how it's better and how a study shows it's better. When I look up the study at the end it says, laser appears can be as effective as traditional treatment. I was like huh, it's not better? It costs $100 more.

So after all that, to appeal you need your dentist to contact the insurance company, it was your dentist who gave a 'not so good explanation' to the insurance company to cause a denial after all.

  Yes, but the proper alternative to an inlay or onlay needed for strength is actually gold -- not an amalgam.

rated:
forbin4040 said:   

So after all that, to appeal you need your dentist to contact the insurance company, it was your dentist who gave a 'not so good explanation' to the insurance company to cause a denial after all.

Exactly. The insurance company isn't "downgrading" anything, they're just not going to pay for bells and whistles beyond what is actually necessary. You can pay for the more expensive stuff if you choose.

If it's truly required, and not just "better", your dentist needs to convince the insurance company.
  

rated:
scotto777 said:   .  However, it seems crazy they could downgrade to an amalgam filling if the dentist is saying my tooth doesn't have the structural support for another filling.  




Did they really say that they won't do an inlay?

Or are they saying that they won't pay for porcelain filling?

They typically won't pay for porcelain fillings.

But denying an inlay is another thing.

rated:
Ask your dentist to appeal. Let us know what they say and how it turns out if they do.

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