An insightful and informative newsletter from the Art of Practice Management. A dental practice management consulting company that focuses on revenue and collection systems, front desk systems and forms, dental insurance processing, medical/dental cross-coding systems and employment-law compliance.

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As a dental-medical cross-coding trainer, I say the following words over and over
again - "the dental procedure must be medically necessary to be reported on a
medical claim." Rarely am I asked how one determines medical necessity. Perhaps
that is because most would consider it to be a simple determination - that anything
performed or prescribed by a medical professional would be medically necessary.
However, it is just not that simple. As we in the dental community deal with the
increasing demand for filing medical claims for our patients, we will need to be able
to accurately determine what procedures are truly medically necessary so that we
can file successful medical claims and avoid financial and legal liabilities.
In my attempt to define medical necessity for my readers, my research has turned
up a myriad of definitions. According to Wikipedia, "medical necessity is generally
considered that which is reasonable, necessary, and/or appropriate based on
evidence-based clinical standards of care."1 Now that seems simple enough till one
really looks closely at it. That statement begs the question - who makes the
decision? Who has the power to make that determination? Should the medical
provider be the one to do that or the medical insurance plan? Then we need to
consider what is truly necessary and what might be elective. Does a medical
condition always necessitate medical intervention? Does acne, hair loss, or infertility
always necessitate medical treatment? Although these are just a few examples of
medical conditions, are they truly medically necessary conditions? There is much to
be considered and there are no easy answers.
First we might ask if there are any regulations that must be followed to determine
medical necessity. The U.S. Department of Health and Human Services reports that
there are very few and that "there is no Federal definition, and only slightly more
than one-third of states have any regulatory definition of medical necessity."2 They
indicate that without such regulations, the final determination on medical necessity
has mostly fallen to the individual insurance contracts that are defined by the
insurer. It can be concluded that most of these insurers have their own unique
definition of medical necessity. What we can deduce from all of this is that, no
matter how much a procedure is consistent with professional clinical standards, if
the insurer does not determine that it falls within its plan description, they will most
likely deny benefits. Thus, the decision on medical necessity for a patient is most
often made by someone who has never even seen the patient.
Medicare includes in its own definition of medical necessity that the service must be
reasonable and necessary for the diagnosis or treatment of illness, injury, or to
Together we will create a practice Masterpiece
Articles
DETERMINING DENTAL/MEDICAL NECESSITY
Marianne Harper

2. improve the function of a malformed body member. Now that sounds like a solid rule
that must be followed but, even so, Medicare has the power to determine on a case-
by-case basis if the procedure was reasonable and necessary.3
We must now consider how we can determine whether certain dental conditions will
be medically necessary. As I stated earlier, there are a multitude of definitions as to
medical necessity. Due to the fact that we cannot possibly know what every plan's
definition is, we will have to determine a generalized definition to follow. A definition
for medical necessity was found on the Family to Family Health Center web-site that
states the following and seems to be a fair and accurate one:
Medically Necessary Services are services required to:
 Diagnose or prevent an illness, injury or condition
 Treat an illness, injury, or condition
 Keep a condition from getting worse
 Lessen pain or severity of the condition
 Help improve the condition
Medically Necessary Services...
 Are consistent with the diagnosis
 Meet accepted standards of good medical practice
 Can be safely provided
Medically necessary requirements for children:
 The service is appropriate for the age and health status of the child
 The service will aid overall physical and mental growth and development;
and/or
 The service will assist in achieving or maintaining functional capacity4
You may now ask how you can safeguard yourself from financial and legal problems
when determining medical necessity for a dental procedure. There are several
protocols that you should follow.
1. Ask questions. Contact the patient's insurance company to determine if the
procedure would be considered a medical necessity and payable under the
plan. This is a good idea in any case so that you can prepare your patient
prior to treatment for their financial responsibility. Remember, not knowing
the rules will not be a strong enough defense.
2. Always thoroughly document all the details about the medical necessity of
the procedure for each patient.
3. Write powerful letters of medical necessity and use these either to pre-
authorize treatment or to appeal a denied claim. These letters also need to
address the consequences of non-treatment.
In conclusion, you should now see the difficulty that medical practices have had with
determinations of medical necessity. It used to be so much simpler for dental
practices. However, with the on-going research into the systemic link, and with the
more frequent denial of benefits by dental carriers requesting that claims be filed
with medical first, there is now a growing need to file certain dental procedures on
medical claims. Remember that not all dental procedures will be considered
medically necessary. The more that we show the medical necessity of those dental
procedures that are medically necessary; the more likely we are to bring about
changes in these plans. Encourage your patients to be the squeaky wheels. Your

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patient and his or her employer have the power to create change. Then, follow the
guidelines in this article to protect yourself.
1
"Wikipedia.org", n.d., <http://www.wikipedia.org/>, (November 6, 2006)
2
"Medical Necessity in Private Health Plans", n.d.,
<http://mentalhealth.samhsa.gov/publications/allpubs/SMA03-3790/default.asp>, (February
11, 2007)
3
Nancy W. Miller, Esq., "What Is Medical Necessity", August 2002,
<http://www.physiciansnews.com/law/802.miller.html>, (November 5, 2006)
4
"Family to Family Health Center", n.d.,
<http://spannj.org/Family2Family/medically_necessary_services.html>, (November 2, 2006)
Favorite Quotes:
In keeping with the theme of "proving" medical necessity and also due to the
upcoming election, the following quote caught my eye:
"The hardest thing about any political campaign is how to win without proving that
you are unworthy of winning"
~ Adlai Stevenson
http://www.brainyquote.com/quotes/keywords/proving.html (October 20, 2016)
Letter of Medical Necessity
Colleen Rutledge, RDH
I received a very interesting email from Waterpik last week. It explained how some
health care services and products are eligible for reimbursement from a health care
FSA, HRA, or HSA only when a licensed health care provider certifies that it is
medically necessary.
In order for our patients to get reimbursed, a "Letter of Medical Necessity" and any
documentation will need to be submitted to the plan administrator. Since plans vary
greatly, it is prudent to advise patients to check first to make sure the product is
covered under their plan.
So, if you have a patient that would like to take advantage of this benefit, they need
the following information from us, the health care provider, in the form of a letter:
 Specified diagnosed condition
 Treatment indicated
 Length of treatment
 How the service/product will alleviate the condition
Sounds like more work for us, right!??? Well Waterpik has done all the work by
developing a letter that contains everything stated in this article! Just click the link
below to get a free copy!
https://www.waterpik.com/oral-health/why-waterpik/FSA-Letter-of-Medical-Necessity-v2_1.pdf
15% OFF on our "Do-It-Yourself" Dental Hygiene Department Consulting Kit
until November 15, 2016! Use code OCTMEZ in your shopping cart.
Visit www.PerioAndBeyond.com to shop now!

4. Dental – The CDT codes update on 1-1-17. One revised code deals with space
maintainers. There will be a new code D1575 for distal shoe space maintainers.
Code D1510 (unilateral space maintainer) will then exclude distal shoe space
maintainers.
Medical – October 1 was the effective date for the update of the ICD-10 diagnosis
code set. There were many new dental related diagnosis codes in this update. This
may indicate that they are aware that more and more dental practices are cross
coding to medical. Most of the new codes are subdivisions to already existing codes
and if you use the existing codes and not one of the subdivision codes you will get
denials. For purchasers of my coding products, now is the time to order the update
so that you will have all of these new codes. You can order your updates by clicking
on the following link: 2017 Code Update
Present – For practices that cross code to medical, the ICD-10 diagnosis codes
updated on 10-1-16. Purchasers of my coding products should be receiving email
reminders as to how to order your updates. If you haven't received an email, you
can click on the following link to place your order: 2017 Code Update
January 1, 2017 – Annual update to the CDT codes
Dental coders should begin researching the updated dental codes and where to
purchase the updated CDT code set. My recommendation is "Coding With
Confidence". A link to order this great coding book is the following: Coding with
Confidence Manual Order Form.
 April 2017 - Abra-Code-Dabra; Michigan Dental Association Annual Session
 August 2017 - Abra-Code-Dabra; Michigan Dental Association
For seminar details visit: www.perioandbeyond.com/calendar.html
Key Decision Makers for Periodontal Protocol
 Friday, November 4, 2016
The Georgian Terrace Hotel - Atlanta, GA
 Saturday, November 5, 2016
Château Élan Winery & Resort - Braselton, GA
To register: 707-769-8887 or register online:
http://lizgrahampresents.com/index.php/seminars/blue-prints
Treatment Planning Non-surgical Perio Therapy Cases
 Sunday, November 6, 2016
Mount Laurel, NJ
To register online: http://www.njdha.org/south.html
Time Line
Insurance Alert
Marianne's Schedule
Colleen's Fall/Winter Speaking Engagements

5. Tips:
Office managers, as you handle issues with your staff relating to optimal patient
experiences and professional conduct, remember that this also applies to you. You
can't expect compliance if your behavior does not match your requirements for
them.
Points of Interest:
This year is the 60th anniversary of Play-Doh. Originally Play-Doh was
simply wallpaper cleaner but when vinyl wallpaper was introduced it
decreased the demand for the product. A preschool teacher made the
suggestion to the owner of the company to make the product into a
modeling clay product. He removed the detergent from the product,
used dyes to color it, added scent to make it more appealing, and then
marketed it to children. Since then more than 3 billion cans of Play-Doh have been
sold.
Liz Loerke, The Simple List, (Real Simple Magazine, September 2016), p. 12
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The Art of Practice Management
2217 Fox Horn Road • New Bern, NC 28562 • Phone: 1-252-637-6259
www.artofpracticemanagement.com • a.p.m.1@suddenlink.net
Perio-Therapeutics & Beyond
724 Fitzwatertown Road • Glenside, PA 19038 • Phone: 267-241-5833
www.perioandbeyond.com • colleen@perioandbeyond.com
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About us | Privacy policy | © Copyright 2016 - Marianne Harper
The contents of this publication reflect the opinion of the authors only. This publication is for informational purposes only.
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