Dear ADA: Downcoding

Association continues to advocate for greater transparency in claims adjudication

Dental insurance issues are often cited as one of dentists’ biggest challenges.

In response to an ADA Health Policy Institute poll in late 2025, more than half of dentists reported that one of their top concerns looking ahead to 2026 was related to insurance, including low insurance reimbursement rates and delayed or denied payments.

This ADA News series aims to address some of those challenges. “Dear ADA” will feature answers to common insurance-related questions the American Dental Association receives from members to help provide clarity and direct members to additional resources.

The answer to this month’s question is provided by Paula Crum, D.D.S., chair of the ADA Council on Dental Benefit Programs’ Coding and Transactions Subcommittee.

Dear ADA: I am concerned about the ongoing issue of downcoding — for example, when a multisurface restoration submitted with proper documentation is unilaterally changed and reimbursed as a single-surface restoration. Since the CDT Code includes clear descriptors that define the procedures performed, I am trying to understand why insurance carriers are permitted to alter these codes in ways that do not reflect the actual treatment provided. Is there anything within the CDT licensing or contractual agreements that outlines remedies or enforcement mechanisms when insurers misuse or disregard CDT Code descriptors in their adjudication processes?

Dr. Crum: Downcoding occurs when a payer reimburses a claim using a procedure code different from the one reported by the dentist, resulting in a lower benefit than would have been paid for the submitted procedure. In the situation you describe, such as a multisurface restoration being reimbursed as a single-surface restoration, the payer is not changing the meaning of the CDT Code but instead applying a different reimbursement based on plan policies or contractual provisions. In a similar downcoding event that I have encountered, four bitewing radiographs were taken and submitted to the third-party payer, but the benefit paid was for two radiographs. It was not until the claim was appealed that we were told that per the patient’s plan provisions, bitewing radiographs are given the benefit of two films in a 12-month period.

It is important to distinguish between reporting a procedure and benefiting a procedure. Dentists are required to report the CDT procedure code that accurately reflects the treatment performed. As mandated by a Health Insurance Portability and Accountability Act standard, payers must accept valid CDT procedure codes for processing. However, HIPAA does not govern how a payer adjudicates claims or determines reimbursement. Instead, benefit plan design, contractual limitations, exclusions and internal adjudication policies generally control payment decisions.

Similarly, payers using the CDT Code must be licensed to do so and must preserve the code number, nomenclature and descriptor as published. However, the CDT copyright license does not dictate reimbursement methodology or require payers to reimburse according to the submitted procedure code. In other words, the license governs how CDT codes are used — not how claims are paid.

That distinction does not mean the ADA supports downcoding practices. In 2016, the ADA adopted policy strongly opposing claims payment abuses by payers, including downcoding and practices that misrepresent the care provided. The ADA continues to advocate for greater transparency and fairness in claims adjudication and maintains that explanation of benefits statements should clearly distinguish between the procedure reported by the dentist and the procedure being reimbursed by the plan.

For example, if a dentist submits a claim for a multisurface restoration and the plan reimburses at a lower level, the EOB should still reflect the CDT code originally submitted and explain how the claim was benefited. Often this language is missing from the EOB, which results in confusion for the patient and can erode patient confidence in the dentist’s clinical judgement and trust in their billing practices. Per ADA policy, EOB language should not imply that the dentist reported an incorrect procedure code when the code accurately reflects the treatment rendered.

The ADA has also raised concerns when plans appear to pressure dentists to misreport procedures. For example, some plans have reportedly rejected claims for code D1110 adult prophylaxis for younger patients with adult dentition and instructed dentists to resubmit code D1120 child prophylaxis based solely on age criteria. The CDT procedure codes for prophylaxis put no age requirements or restrictions within the descriptors for either D1110 or D1120. While a plan may apply its own benefit limitations, dentists should report the code that accurately reflects the procedure performed and should not be required to alter clinical reporting to conform to a payer’s payment preference. If you encounter this type of situation, the ADA encourages dentists to seek guidance and report concerning practices.

In-network contracts may further complicate these issues because reimbursement methodologies are often embedded in payer agreements. Before signing a network contract, dentists may wish to review the ADA’s resources on dental insurance contracts or use the contract analysis service, available through participating state and local dental societies, which provides a plain-language explanation of contract provisions. While the service does not provide legal advice or recommend whether an agreement should be signed, it can help dentists better understand reimbursement language and claims-processing terms.

If you believe a claim was improperly adjudicated, begin by carefully reviewing the EOB language. If the EOB acknowledges that the reimbursement was based on the benefit plan’s design, then there is no need to appeal. If there is no explanation on the EOB, as is often the case, then appealing the determination in writing should be done. Maintain supporting clinical documentation and request clarification of the payer’s rationale. Appealing these claims can put administrative burden on the dental practice, but the result of the appeal can also be very beneficial to the dentist-patient relationship by forcing the payer to explain their rationale for the benefit paid.

The ADA continues to urge dentists and state dental associations to remain vigilant, challenge problematic claims practices and appeal downcoded claims when appropriate. When in doubt, ADA members can contact the ADA Third Party Payer Concierge for complimentary help resolving dental insurance questions or issues. Members can reach the concierge by email at dentalbenefits@ada.org.