ADA urges Principal to reconsider documentation for periapical radiographs

Association takes immediate action after learning of Feb. 19 notice to providers

The American Dental Association has contacted and received clarification from Principal dental insurance after dentists received a notice stating the company is now requesting additional documentation for periapical radiographs taken during “a routine hygiene visit.”

After learning of the Feb. 19 communication to providers, ADA leaders from the Council on Dental Benefit Programs and staff met Feb. 20 with senior Principal representatives, who agreed their policy change required clarification.

ADA leadership questioned the need for the carrier’s policy given that the recommendations regarding frequency of radiographs for new and recall patients have remained unchanged for more than a decade. They highlighted the need for clarity on the policy and stressed the administrative burden this policy places on dental offices already affected by inflationary pressures and workforce shortages.

The ADA’s understanding of Principal’s intent is that:  

• They are only reviewing claims that include two or more periapical radiographs reported with code D0120 periodic oral evaluation or code D1110 adult prophylaxis.

• They are requiring a narrative on claims based on patient-specific needs rather than routine practice.

• This documentation may include positive or negative clinical findings, as negative findings can also establish the necessity for radiographic assessment when symptoms, history or clinical concerns warrant further evaluation.

• They are requiring copies of the periapical radiographs.

• A benefit determination is made on all other service lines. If a clinical need for periapical radiographs is not documented, this information will be requested so a benefit determination can be made accordingly.    

The representatives from Principal indicated they are unable to pause implementation of this policy but agreed to clarify it online and for dentists in their network, acknowledging the confusion caused by the Feb. 19 notification.

“The meeting with Principal provided the clarity our member dentists deserve. However, despite the clarification offered, the ADA does not agree with Principal’s policy change,” said Shelley Olson, D.D.S., chair of the ADA Council on Dental Benefit Programs.

“Dentists understand the ALARA, or As Low As Reasonably Achievable, principle to minimize radiation exposure over a patient’s lifetime, and we continue to promote the need for documentation supporting treatment plans within the patient record,” Dr. Olson continued. “However, the administrative burden created by required documentation on the claim form justifying two or more periapicals performed as part of a clinical examination, subsequent denials, and need for resubmissions and appeals creates an unacceptable burden on dental offices.”

“Decisions about care should be made between dentists and their patients and be based on dentists’ clinical judgment informed by published guidelines,” she concluded.

The Council on Dental Benefit Programs will continue to advocate on behalf of dentists and their patients on this issue and will share further developments with ADA members.