Insurance says my treatment didn't meet its criteria. What does that mean?
The short answer
It means your plan does cover this kind of treatment, but after reviewing the records for your case, it decided this claim didn't meet its rules for payment. It's a payment decision based on what the plan could see in the records, not a verdict on whether you needed the care.
How this is different from “not covered”
- Not covered (excluded): the plan never pays for this treatment, for anyone. See Why doesn't my plan cover this at all?
- Criteria not met: the plan pays for this treatment when a case meets certain conditions. It checks those conditions by reviewing the X-rays, photos, or gum measurements your dentist's office sends, and these decisions are usually made by a licensed dentist.
Where it comes up most
Tap the one that matches your bill.
Deep cleanings
Also called scaling and root planing. Plans usually look for gum disease of a certain severity, such as deeper pockets between the gums and teeth and bone loss visible on X-rays. If only some areas of your mouth meet the criteria, the plan may pay for a deep cleaning in just those areas.
Crowns and buildups
A buildup is the filling material that rebuilds a tooth's core so a crown has something to hold on to. Plans usually look for a certain amount of lost tooth structure, from decay, a crack, or a large old filling. A tooth with a smaller problem may qualify for a filling instead.
Fillings and crowns for worn teeth
Many plans pay for fillings and crowns only when the damage comes from decay, a failing old filling or crown, or a break. They don't pay when it comes from wear: teeth worn down by grinding, by brushing too hard, or by acid from foods, drinks, or reflux, including small notches near the gum line. A break caused by wear, such as from grinding, may count as wear too. The plan goes by the cause described in your dentist's records and shown in the X-rays they send.
Bridges
This comes up less often. Plans may look at the health of the teeth that will hold the bridge. Long bridges that replace several teeth in a row get a closer look, because they're less predictable over time.
Tooth removal, including wisdom teeth
Removing a tooth is billed at different levels, from a simple removal up to a tooth fully stuck in the jawbone. Plans look at your X-rays to judge how involved the removal was. If it looks less involved than the level billed, the plan may pay for a simpler level.
Teeth that never formed
Some plans don't pay to replace a tooth you were born without, and the reviewing dentist spots this from your records. It's easy to confuse with the missing tooth clause; see how the two differ.
Any major treatment: the tooth's outlook
Plans generally won't pay for treatment on a tooth that's unlikely to last, such as a tooth with severe bone loss around it or an infection that hasn't been treated. Dentists call this the tooth's prognosis.
Why the plan and your dentist may see it differently
A denial like this can feel like the plan is saying you didn't need the treatment. That's not quite what it means. Common reasons include:
- An X-ray doesn't tell the whole story. It's a flat, two-dimensional picture, and the reviewing dentist can't see or test your tooth the way your dentist did in person. A crack, or how the tooth responds when you bite, may not show up on an X-ray at all.
- Plan rules are written for coverage, not for your mouth. They set when the plan pays. Your dentist may reasonably recommend care beyond those rules, the same way they may recommend cleanings more often than a plan covers.
- Some cases are borderline, and reasonable dentists can disagree.
If the denial leaves you unsure whether you needed the treatment, that's a fair question to bring to your dentist, and a good time to consider a second opinion.
What you can do
- Find the exact reason on your Explanation of Benefits. Criteria denials usually explain the specific reason for your case.
- Ask your dentist's office to send more information, such as photos or a note describing what they saw that's hard to see on an X-ray, like a crack, and ask the plan to review it again.
- Appeal if the plan still says no and you and your dentist disagree.
What you'll owe
If your dentist is in your plan's network, whether they can bill you for treatment denied this way depends on your plan, and it can even depend on the type of denial:
- Sometimes you can be billed. A crown can still be the right treatment for a tooth even when it doesn't meet the plan's criteria for payment. In cases like that, plans often let the dentist charge you for it.
- Sometimes you can't. When the plan's decision is that the treatment doesn't fit the tooth, such as treatment on a tooth that's unlikely to last, plans often don't let an in-network dentist bill you. Some plans treat a deep cleaning without enough bone loss the same way.
Your Explanation of Benefits shows whether the amount is yours to pay. Check it, and ask the office, before you pay. If your dentist is out of network, they haven't agreed to your plan's rules, so they can generally bill you for whatever the plan doesn't pay.
Next time: catch it before treatment
A predetermination sends the same records to the plan before treatment, so a criteria problem usually shows up while you can still decide what to do.
Questions to ask
- Can you show me what you saw on the X-ray or photos?
- Did the claim include photos or a note describing what you saw?
- Can you send more information and ask the plan to review it again?
- If the plan won't pay, what will I owe, and does my plan's contract allow that?
When a second opinion makes sense
Consider one if the denial leaves you unsure whether you needed the treatment, especially for deep cleanings, or for crowns on teeth with little decay or only a small filling.