One of my great friends who also teaches dental shared this question with me.  I am happy to pass this on to you......

Q: I’m having trouble obtaining payment for a pulp cap that was placed beneath a crown and crown buildup. Do you have any advice on writing a narrative for this?


A: Pulp caps can be difficult procedures to appeal. Many times they’re considered part of the filling or buildup procedure. For plans that cover the procedure, these are usually reimbursed without the need for documentation. However, you may run into situations where the procedure is denied because it was rolled into the allowable payment for the restoration. In this case you may wish to appeal the decision. You’ll need a good narrative and supporting images. A radiograph of the tooth will be needed, and if you can, send an intraoral image of the tooth pre-restoration placement (preferably with the old filling and decay removed so the consultant can see the extent of the damage). Below is a sample narrative for your use. Using your doctor’s notes and this template you can file the appeal. Always be sure that your clinical documentation and claims information match. 

A buildup was placed on tooth No. 18 for the following reason: the mesiolingual cusp was fractured off and there was decay present. After all the decay and existing amalgam filling were removed, a buildup was necessary for placement of a crown on No. 18. A crown would not have been ideally placed without this buildup. Also, when the buildup was placed on tooth No. 19, Dr. Smith felt that he was very close to the pulp chamber. A pulp cap was placed for this reason. Please refer to the submitted X-ray for your evaluation of the buildup on Nos. 18 and 19. 


Christine Taxin
Links2Success
36 Abington Avenue
Ardsley, New York 10502
United States of America