Q. What is a “Missing Tooth Clause”?

A. A missing tooth clause allows an insurance plan to deny coverage for replacing a tooth if it was missing before the policy began—even if the tooth was lost years ago. This commonly affects coverage for bridges, partial dentures, or implants.

Many patients are unaware this clause exists until treatment is denied.

Q. What is a Waiting Period?

A. A waiting period is a required amount of time you must have coverage before certain procedures are eligible for benefits. Major services such as crowns, periodontal treatment, or tooth replacement often have waiting periods ranging from 6 to 12 months.

During this time, treatment may still be needed—but insurance will not contribute.

Q. Why Does Insurance Deny Treatment My Dentist Recommends?

A. Insurance approval does not mean a procedure is necessary, and denial does not mean it isn’t. Insurance companies determine coverage based on plan limitations—not clinical judgment.

Dentists diagnose based on health, function, and risk. Insurance reviews claims based on contracts and cost controls.

Q. What Does “Usual, Customary, and Reasonable” (UCR) Mean?

A. UCR refers to the maximum amount an insurance plan is willing to consider for a procedure—not the actual cost of care. These limits are very often outdated and may not reflect modern materials, technology, or practice costs. UCR is not a standard number; the allowed amount for the same procedure can vary widely based on location, insurance company, and the specific plan contract.

If the plan’s allowed amount is lower than the actual fee, the patient is responsible for the difference.