Why do my MO and DO restorations not receive separate benefits when they are clearly two separate restorations?

The reality is there are 5 possible surfaces available for the restoration of any tooth. Occlusal or Incisal, Mesial, Distal or Facial, and the Lingual.  Most carriers have software programs that will only consider the surface once per tooth as a single surface.  Confusing right?  Let’s talk dental examples, this may help to clarify.

For example, if there are two or more occlusal pits on a posterior tooth, most carriers will consider that as a single one surface occlusal restoration; MO and DO submitted on the same tooth will usually get benefited as an MOD. Carriers will only pay for the occlusal surface once on the same tooth so the benefit is issued as MOD.  From a clinical standpoint, we could essentially connect the occlusal restorations to form one MOD restoration.

Let’s consider a mesial-occlusal pit plus an occlusal-lingual fissure in a maxillary molar - this is usually considered as a three-surface (MOL restoration).  In this case, the mesial would be benefited, the occlusal (once) and the lingual.

What if an occlusal-buccal or occlusal-lingual plus a separate Class V restoration is submitted? Most likely you would receive benefits for one 2-surface restoration (the OB or the OL) and second 1-surface restoration (Class V) because clinically these surfaces cannot be connected.

Let’s make it more confusing - let’s say you submitted for #8 mesial and #8 distal.  These are two separate restorations that shouldn’t be grouped together as a single 2-surface restoration because theoretically, they shouldn’t be contiguous.

Keep in mind, the carriers are making a benefit determination based on your patient’s plan design and THEIR internal processing guidelines.  This can be very different from the standard of care and training we are familiar with.  A benefit determination is not a recommendation or determination as to whether the treatment is warranted.  You have a responsibility to treat your patient based on their medical necessity, not based on their insurance coverage.

Frequently we receive denials and a narrative stating something to the effect that “Benefits are not provided for duplicate charges”.  Next time this happens, you will have a better idea of why/how the carriers handle these submissions.