Medical Necessity, just what does that mean?

By Belle DuCharme, CDPMA, Director of Training Programs for eAssist

In today’s world of dental claims the term “medical necessity”  used to be referenced to medical claims only and was not a concern for dentists and their business teams.  Recently dental claims have been denied for payment because of lack of proof of medical necessity for the procedure.  This has included  restorative crowns, sealants and  surgical procedures.  It is a policy provision in the individual plan or group and has nothing to do with the dentist’s diagnosis as to what is best for the patient.

Medical necessity is defined by the payer of the claim.  As such there are standard elements that payers consider when making a determination.  The procedure should be clinically appropriate for the patient’s diagnosed condition and must be delivered within the recognized and approved standard of care.  Payers are also looking for the least costly procedure that will satisfy the needs of the patient’s care.  

Medical necessity can be established by using the proper and current CDT codes accompanied by documents and supporting evidence when appropriate such as radiographs, intra-oral photos, periodontal charting, excellent written narratives and reports from physicians or specialists.   Using the ICD-10 diagnosis codes on the ADA 2012 claim form or when necessary on the CMS 1500 medical claim is very important to establish medical necessity in the language that health care payers understand.  Many dental practices are not prepared for this type of coding but eAssist is and can help.


eAssist Helpful News and Billing Tips; Edition #103


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