Doctors: Does United Concordia Make You See RED?

Patient Name:   
Date of Service:

Date of Predetermination:

Service Declined: ? Yes  -  Reason Given:
Service Approved and Paid For: ? Yes - 

Predetermination Approved: ?
Predetermination Declined: ? Reason Given: 
Predetermination declination appealed: ? Date:
Explanations provided on original insurance form
Additional information provided with original form

Explanations provided on appealed form:
Additional infromation provided with appealed form:

Services were actually rendered on this patient and the claim remains unpaid for the following services:

On the submission for payment the following explanations were provided:

On our appeal the additional information annotated below was provided:

• In looking at the information provided, we feel that approval should have been given, or payment made for the following reasons.
•  Your claims reviewer could not possibly determine the presence of decay.  All he has is a pencil, we have an explorer, loupes, and intraoral camera at our disposal
• If you look closely at the xray, you will see a change in the density of the dentin at the DEJ.
• The existing amalgam in the tooth had an open margin, which could not possibly be detected by your reviewer.  It is our experience that when an explorer firmly sticks in such a lesion, that there is decay present, which should not be left to be observed.  
• The existing amalgam in the tooth had caused a crack to form on the marginal ridge.  It is our experience that when these fillings are removed, it is found that the crack allows the invasion of micro organisms that initiate the decay process.  A photograph of such a tooth has been enclosed.  It shows what we find on a routine basis: that decay is always present.  Notwithstanding that fact, the amalgam acts as a wedge, and through thermocycling causes the tooth to crack further, whereas a bonded resin filling will help prevent the propagation of the crack.
• There is no way a claims reviewer can determine the necessity for a filling on the Buccal surface of the tooth by looking at a radiograph.
• Patient declined X-rays, decay was discovered on exam with a dental explorer.
•  Other:

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