Beware of Sealants and Their “Hidden” Limitations
Estela Vargas, CRDH, CEO Remote Sourcing
From the ADA, the CDT Code D1351 is described as- Sealant per tooth, mechanically and /or chemically prepared enamel surface sealed to prevent decay. The enamel surface is not carious when the sealant is applied.
According to the Center for Disease Control, once applied, sealants protect against 80% of cavities for 2 years and continue to protect against 50% of cavities for up to 4 years. Children aged 6 to 11 years without sealants have almost three times more first molar cavities than children with sealants.
The pit-and-fissure sealant procedure has been around for over 50 years. It is to prevent caries on primary and permanent teeth of children and adults. Despite the proven results to seal out decay, sealants are still underutilized by many dentists.
Why is that? When sealants are diagnosed and recommended, the patient or parents or guardians often don’t see the preventive value and don’t want to pay out of pocket unless they see the “need” such as a cavity.
Contract limitations on insurance plans limiting reimbursement for sealants further hinder access to this necessary care for children. Contract limitations may include:
- Not usually a covered benefit for adults
- Should be applied to primary teeth but is usually not a covered benefit
- A restoration such as amalgam/composite on the same tooth on the same day is considered a global fee and not paid separately
- Sealant coverage generally limited to the occlusal surface of permanent first and second molars
- There may be contract exclusions for a sealant placed on a tooth that has a previous restoration on the occlusal surface
- There are age limitations on sealants on permanent molars usually between 15 to 18 years of age. Some plans cover first molars only from age 6-10. Most plan payers have an age limit, there is no standard–please do an insurance verification
- Plans vary on how they catigorize a sealant. It could be preventive, basic or major depending upon the contract and will vary in amount paid
By using Remote Sourcing’s Insurance Verification services, we learn which insurance companies and group plans policies limit how much and how often they pay for sealant procedures. We have seen an increase in claim denials for sealants. Commonly, the hidden limitation or the fine print in the policy is that sealants will only be covered for first molars, 3, 14, 19, and 30 up to the age of seven because it is assumed the molars will be fully erupted by this age. The second molars, 2, 15, 18, and 31, erupt by age 14. Receiving the information prior to treating the patient helps to secure a firm financial arrangement with no surprises. Sometimes the insurance companies make mistakes with the age of the patients or the eruption of the molar teeth. We will then be able to appeal the claim.
Community Preventive Services Task Force. Preventing Dental Caries: School-based Dental Sealant Delivery Programs. Atlanta, GA: US Department of Health and Human Services, Community Preventive Services Task Force; 2016. https://www.thecommunityguide.org/findings/dental-caries-cavities-school-based-dental-sealant-delivery-programs
https://www.cdc.gov/oralhealth/fast-facts/dental-sealants/index.html
