Q&A: Crown Narratives - Decay Not Obvious on X-Ray
What kind of narrative should I send in the following situation? Tooth #30 has an existing occlusal amalgam with recurrent mesial decay visible on the x-ray and Class V wrap around decay that is not visible on the x-ray. In the radiograph it looks like the tooth needs just a two surface restoration. However, all the cusps are undermined once the decay is excavated, and the tooth is too weak to support an amalgam/composite restoration. A crown is clearly needed, but it is always denied by insurance. However, if I do a filling initially and then do a crown a few months later, the crown is approved because it is then obvious on the radiograph that a crown is needed. I do not want to put patients through an extra procedure and added expense when the tooth clearly needs a crown in the first place, but patients are understandably upset when their crowns are not paid. Please help.
Unless you happen to know that a dental plan does not review single crown claims, always send a brief narrative when the condition of the tooth is not readily apparent on the x-ray. Since Class V decay is often not apparent on an x-ray, send a narrative along with a periapical x-ray (rather than a bitewing). The periapical is needed to show that the tooth is endodontically and periodontally sound. Based on what you have described, the narrative might be written as follows: #30 mesial decay and recurrent decay around existing occlusal amalgam. #30 also has Class V wrap-around decay on buccal, lingual, mesial, and distal, which is not visible on x-ray. Hopefully, the narrative along with a clear, readable, properly angulated x-ray will fully explain the condition of the tooth. While not required, sometimes photos show what is not apparent on an x-ray. If you have a good clear photo of #30 showing the Class V decay, send it along with the narrative and x-ray. If the initial crown claim is denied, appeal the denial, making sure to include all of the information mentioned above. Some carriers only read the remarks written in field 35 of the dental claim form in certain situations, and sometimes narratives are truncated by the time they travel through several electronic clearinghouses and reach their final destination. Appeals are often successful simply because a different dental consultant reviews the claim—one who may be more willing to give you the benefit of the doubt when the decay is not obvious on the x-ray and you have included a detailed, individualized narrative.