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Dr. Hall-
My dentist’s treatment plan calls for two lower 3-crown bridges for the second back tooth forward on each side. The dentist advises porcelain fused to metal crown/bridges—due to it being a stronger material to resist grinding pressures—and wants 20% additional $$ above the PPO contract rate for the “upgraded” crown materials vs. all porcelain crown/bridges.
I have three questions:
1. Which type of crown is better and will have best chance against cracking?
2. The 20% “upcharge” labeled as “lab fees” is not a covered code by my insurance. Can a dentist charge above the PPO contract rate and refuse to use the “standard ” porcelain/ceramic crown which is covered by insurance? It seems to me that it is a “work-around” the contract rate, effectively avoiding the limited contract rate fee.
Though I may prefer to have the PFM bridges if they are indeed stronger. I simply may not be able to afford this mandated “upgrade” and I do not think I should have to switch dentists as a result of this, since he is an “in-network provider.”
3. I have all porcelain upper bridges on each side, so my other concern is will the lower PFM crowns grinding against the “all porcelain” upper crowns cause the upper to more likely crack sooner, as I will have stronger material grinding against softer material as opposed to a like material against a like material? Does that make sense?
Thank you.
-Tom from Ohio
Tom,
If you are communicating this accurately to me, then there is indeed some funny business going on with your dentist trying to get away with charging above the contract rate for your bridges. It certainly sounds to me like he or she is playing games with terminology and fees. Let’s address that first.
To sort this out, we need to clarify the terminology here.
First, for the benefit of readers who may not know, a PPO is a preferred provider organization, which is a network of dentist providers that have made an agreement with an insurance company to offer discounted fees to the subscribers of the plan being offered by the insurance company.
Then, as far as the types of crowns, my guess is that your dentist, for the crowns that are a part of the bridges, is using the procedure code D6740 – retainer crown porcelain/ceramic. Notice the term “ceramic” in this procedure code. That’s important. Porcelain isn’t strong enough to serve as a bridge even on the front teeth, much less on the back teeth. It will crack under chewing pressure. But there are other ceramics that are plenty strong enough, and many dentists are now offering these metal-free bridges. I can’t help but assume that we’re talking about one of these higher-strength ceramics here and not porcelain.
But now you’re saying that your dentist wants to “upgrade” to a porcelain fused to metal crown. A couple of problems with these games he or she seems to be playing with the terminology. First, to me the upgrade would be the other way around. The higher strength all ceramic crowns would generally be more expensive. Second, there are procedure codes for porcelain fused to metal crowns and I’m sure the insurance company would have that on their fee schedule. There are three codes for porcelain fused to metal crowns: D6750, D6751 and D6752 for porcelain fused to high noble, base metal, or noble metal respectively. Now it’s possible that the PPO will not pay for the bridge if the metal is high noble. But the noble metal is actually stronger and unless they are really cheap, they should have a fee for that.
And the idea that this “upgrade” is mandatory—that seems to me to be a violation of his contract with the insurance company. The dentist can offer you an upgrade as an option, but he or she has to give you the choice of doing the service that is covered by your plan.
About your other two questions:
The porcelain fused to metal is a little stronger, but the high-strength ceramic is plenty strong enough for a bridge on back teeth.
As far as compatibility with the upper bridges, yes, you are better off having similar materials chewing against each other. Neither one is going to “crack,” but they will wear. You would be best off contacting the dentist who did the upper bridges and finding out exactly what was used on the chewing surface and matching that. You have these high-strength ceramics, but they are often made of a framework veneered with a porcelain.
Then I have a final question for you. Let’s say you tell your dentist no, you want the porcelain/ceramic crowns because you understand that is your right under your insurance plan. Will he or she give you then the high-strength zirconia ceramic? Or will you get the porcelain which won’t hold up? Bottom line—do you trust this dentist?
– Dr. Hall
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About David A. Hall
Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.
Dr. Hall-
A follow -up in reviewing the codes for my treatment plan are as follows:
Tooth # Code
19 O6740
20 O6245
21 O6740
22 O2740
27 O2740
28 O6740
29 O6245
30 O6740
There is a corresponding “lab fee” of $150 each for the above listed crowns for an additional total of $1,200 for the ” crown upgrade charge”.
Is this reasonable, and as you previously stated shouldn’t I have an option to such upgraded crowns? My feeling is…I may want leather seats in my new car, but due to additional cost, I may have to settle for cloth?
Is this even in compliance with the PPO rules?
Thank you again!
Great Help!
Tom
Response by Dr. Hall – I wrote back to Tom and said that these were the codes for the all-ceramic bridgework that his dentist was going to report to the insurance company, and I asked him to go back to his dentist and find out what he was actually going to use, not what was reported. He got back to me and said that the dentist said it was going to be porcelain fused to high noble. And then he added that after he asked this, the dentist offered to do the all-ceramic bridges without the added $150 per unit.
Here’s my response to Tom:
Tom,
Okay this clarifies what is going on. It’s what I suspected, but your dentist still hasn’t come clean. It’s taking advantage of a technicality, but if the insurance company found out what he or she was doing, your dentist would be in trouble.
So this is how your dentist is getting around this. To help make this clear to you, I’m going to make some assumptions of what is going on here. I’m pretty confident of these assumptions, but not entirely sure, so take these comments in that context. But I want to avoid the complexities of dealing with all the possibilities by just giving the most likely scenario.
There are four basic types of porcelain bridges: porcelain to base metal, porcelain to noble, porcelain to high noble, and all ceramic. It seems that your insurance covers three of those–everything but the porcelain to high noble. Of the three that your insurance covers, the highest reimbursement rate from the insurance would probably be the all ceramic. So, to get the best reimbursement, your dentist submits that to the insurance, and then bills you the laboratory charge for the porcelain to high noble, maximizing his or her profit.
If your dentist were being honest in the billing and really wanted to do the porcelain to high noble, he or she would report a porcelain to noble procedure and then bill you for the difference in the lab fee between the noble and the high noble, rather than the entire lab fee. But he or she doesn’t do that, I’m guessing for two reasons:
1. It would be harder to get you to go along with that. You would be inclined to question the need for the more expensive metal. Much easier to claim this is a stronger bridge because of the metal and sell you on the difference between porcelain and porcelain reinforced with metal.
and 2. The insurance pays more for the all-ceramic bridge, and your dentist wants that extra reimbursement.
If I were you, given the questionable ethics of this dentist, I would ask your dentist to do porcelain to noble. This is the standard porcelain-to-metal bridge. If strength is the concern your dentist is selling, the porcelain to noble is actually stronger than porcelain to high noble, because the metal with less gold in it is stiffer.
– Dr. Hall
Dr. Hall-
I fully understand after reading your explanation re: various angles being played re: insurance filings vs. actual work completed requiring more $$ for lab fees from me.
I am going to follow your advice and request the porcelain to noble.
I can’t thank you enough for helping me decipher the secret code which appeared to be going on here.
Thanks. Best.
Tom