Dental insurance and caries management by risk assessment (CAMBRA)

There are many misconceptions within the public perception of dentistry surrounding dental insurance. The first and most important is the idea that “dental insurance” is “insurance” at all. When individuals purchase “insurance", the purpose is primarily to protect themselves from an unlikely event or situation that would cost a significant amount of money—for example, the loss of a house in a fire, or being diagnosed with cancer requiring hundreds of thousands of dollars in medical procedures. This is true for most types of insurance as the insurance company collects small monthly premiums from a large number of participants and pays out loss-connected benefits according to their policies on statistically rare events or situations. This is the true definition of insurance. Fire insurance, life insurance, homeowner’s insurance, and even medical insurance all come under this definition.

A better definition of dental insurance is that it is more of a “dental benefit.” Dentistry is not a rare event, and according to the CDC, 85% of all adults experience dental decay. The cost of this care, while it is not inexpensive, does not accumulate to the levels of unexpected surgery and a long-term medical stay or replacing a home. Consequently, the classic model of insurance doesn’t work well in dentistry. For that reason, in the 1960s, dental insurance was invented as an employer-sponsored benefit to assist employees in offsetting the costs of regular dental maintenance. But because so many individuals have dental needs, in order to offer the dental insurance, caps were put in place to limit the benefit to $1,000–$2,000 per year in most cases.

Due to this cap, most policies that are purchased by individuals, employers, and employees primarily include coverage for regular cleaning visits and restorative work like fillings and crowns. Although policies do exist with coverage for preventive therapies and other necessary dental procedures, often, dental customers choose insurance policies with a focus on restorative and regular checkup benefits based on a treatment model of care, not a wellness model.

The next most prominent misconception regarding dental insurance occurs when patients believe that their dental benefit covers all of their necessary oral health care needs, and anything that is not covered by their benefit is not necessary to maintain their oral health. This is often a real frustration for both dental practitioners and patients. For example, a patient presents with 4 new cavities and periodontal (gum) disease and has caries risk factors and a high biofilm challenge (caries infection). In order to adequately treat the patient and make strides toward health, all areas of decay need to be removed and filled, periodontal therapy performed, and antibacterial caries therapy started. But the patient only has enough dental benefits to cover 2 of the 4 necessary fillings and does not want to move forward with any treatment that is not covered by their benefit.

While “out of pocket” financial implications of dental and medical treatment are always a consideration, and for some, the costs are an insurmountable obstacle, untreated dental disease and untreated oral infections like periodontal disease and caries are extremely unlikely to “heal” on their own. Patients who do not take immediate action to repair and treat the disease, or allow their dental benefits to guide their treatment plan, will face amplified progression of the disease and increased costs. For some patients, this is a frustrating downward spiral, and eventually, they reach a “point of no return” and opt to have their teeth removed. This entire book is designed to help stop that process.

The truth is that dental insurance is a product, and what type of procedures covered and the limitations of coverage are bundled into different “policies” or packages, which are then sold to employers or individuals. The dental insurance policies are designed to do three important things: The insurance plan must fit the insurance company’s financial needs for profitability. The plan must meet the annual policy price points expected by employers, employees, and individuals. And finally, the plan must provide adequate procedure compensation for the provider (dental practice).

Currently, multiple insurance companies sell policies with coverage for dental procedure codes associated with CAMBRA, including “D0425” for caries susceptibility testing (CariScreen), “D1206” for therapeutic applications of fluoride varnish for moderate- or high-caries-risk patients, “D1310” for nutritional counseling for the control of dental disease, and “D9630” for other drugs, medicaments, or fluoride dispensed by the office for at-home use (see chart of all codes). While this list is not all-inclusive and many other CAMBRA procedure codes exist, many patients believe that if their insurance policy doesn’t cover caries susceptibility testing or drugs and medicaments dispensed by the practice for the control of dental disease, the recommendations being made are not necessary for health. This is simply not true.

Insurance Billing Codes Related to CAMBRA

D0145. Oral evaluation for a patient under 3 years of age and counseling with primary caregiver.

Diagnostic and preventive services performed for a child under the age of 3, preferably within the first six months of the eruption of the first primary tooth, including recording the oral and physical health history, evaluation of caries susceptibility, development of an appropriate preventive oral health regimen, and communication with and counseling of the child’s parent, legal guardian, and/or primary caregiver.

D0415. Collection of microorganisms for culture and sensitivity.

D0417. Collection and preparation of saliva sample for laboratory diagnostic testing.

D0418. Analysis of saliva sample, chemical or biological analysis of saliva sample for diagnostic purposes.

D0421. Genetic test for susceptibility to oral diseases.

Sample collection for the purpose of certified laboratory analysis to detect specific genetic variations associated with increased susceptibility for oral disease such as severe periodontal disease.

D0425. Caries susceptibility tests, diagnostic test for determining a patient’s propensity for caries.

D1110. Prophylaxis—adult.

Removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.

D1206. Topical application of fluoride varnish.

Prescription strength fluoride product designed solely for use in the dental office, delivered to the dentition under the direct supervision of a dental professional. Fluoride must be applied separately from prophylaxis paste.

D1208. Topical application of fluoride.

D1310. Nutritional counseling for control of dental disease.

Counseling on food selection and dietary habits as a part of treatment and control of periodontal disease and caries.

D1320. Tobacco counseling for the control and prevention of oral disease.

Tobacco prevention and cessation services reduce patient risks of developing tobacco-related oral diseases and conditions and improve prognosis for certain dental therapies.

D1330. Oral hygiene instruction. This may include instructions for home care.

Examples include tooth brushing technique, flossing, and use of special oral hygiene aids.

D1351. Sealant—per tooth. Mechanically and/or chemically prepared enamel surface sealed to prevent decay.

D1352. Preventive resin restoration in a moderate- to high-caries-risk patient’s permanent tooth.

Conservative restoration of an active cavitated lesion in a pit or fissure that does not extend into dentin; includes placement of a sealant in any radiating noncarious fissures or pits.

D9630. Other drugs and/or medicaments, by report. Includes, but is not limited to, oral antibiotics, oral analgesics, and topical fluoride dispensed in the office for home use; does not include writing prescriptions.

D9920. Behavior management, by report.

May be reported in addition to treatment provided. Should be reported in 15-minute increments.

D9970. Enamel microabrasion.

The removal of discolored surface enamel defects resulting from altered mineralization or decalcification of the superficial enamel layer. Submit per treatment visit.

Source: CDT® 2011–2012, The ADA® Practical Guide to Dental Procedure Codes Book