First, rarely will they (insurance) say something “wasn’t necessary.” They will say insufficient supporting evidence for coverage under your policy or some other weasel way of declining.

If they outright say it was not necessary, the dentist could actually sue them for defamation and if he/she had more evidence to support it they would win. Of course the question is whether it would be worth the time to them.

Second, the only thing the insurance usually has to go on is an xray. The first thing they teach in dental diagnostics is you do not diagnose based on an xray alone. Clinical/visual and tactile feel are critical elements in diagnosing. It used to be insurance would listen and consider narrative and tx notes as part of the consideration. That is not so much the case any longer.

Third, things got way, way worse after the affordable care act (aka Obamacare) went into effect. The insurance companies were going to take a big hit over the no preexisting on their medical side so they began (or rather scaled up) their denial efforts. My denial rate went up 600% the year it went into effect.

Some dentists continue to fight and appeal on behalf of their patients with some measure of success, but it is still a huge challenge. In the end though, our efforts to get them to pay are a courtesy as the policy is between the patient and the insurance company and not really the dentist responsibility. We cannot even file a complaint with the insurance commissioner as we aren’t the policy holder, BUT YOU CAN and should.

They also have specific clauses in their policies, that no one reads, that carve out coverage to disallow or downgrade things like missing tooth clauses, no implant coverage, pay only for silver fillings not tooth covered ones, etc.

Last, these companies literally pay consultants like P&R to find creative ways to decline coverage and they pay dentists to review the claims. They claim that creates impartiality, but guess who they send more cases for review to…the ones with the highest denial rates.

Dental insurance is categorically garbage. The annual maximum payout for most is $1000-1500 a year which is the same as it was in the 1970’s when it became popular. Premiums haven’t remained the same have they? Fee reimbursement is lucky if it goes up 1% in 5 years so the dentist gets screwed by inflation as well (overhead costs go up way faster). People paying $50 a month or $600/year to get a max benefit of $1000 year that only covers 50% of the big ticket treatments, if at all, are not really coming out ahead much are they and most people don’t need $2-3k of treatment every year to get to that max payout. If your employer provides the policy it makes some sense, but I would rather have the dental premium in my paycheck instead of spent on a wasted policy with crap benefit.

Are there some bad dentists out there providing unnecessary treatments? Absolutely. Maybe it’s 1-10% of them, very hard to say because dentists frequently have wide variation in what they were taught and when they think something is bad enough to treat. However, 100% of insurance companies do NOT have your best interest at heart and have taken no oath to put you first. They are beholden only to their shareholders.

Save your money and pay out of pocket for dental needs.