A dental practice experienced repeated denials from Keystone First (Medicaid MCO) for D2991 – Application of Hydroxyapatite Regeneration Medicament when patients had a prior history of D1351 (Sealant) on the same tooth.
These denials do not align with Pennsylvania Medicaid dental coverage guidelines, which do not restrict D2991 based on prior sealant history.
Our team reviewed:
The pattern indicated that denials were being triggered by benefit administration edits, rather than actual Medicaid coverage limitations.
We escalated the issue and are working closely with Keystone First.
The payer has acknowledged that the denials are likely due to system-level edits managed by DentaQuest (their benefit administrator) and not reflective of Medicaid policy.
Keystone is currently coordinating with DentaQuest to update their systems and correct the claim processing logic.
The issue remains in progress, with ongoing communication between our team and the payer.
We continue to monitor developments and advocate for correction to ensure claims are reprocessed in accordance with Pennsylvania Medicaid guidelines and practices are appropriately reimbursed.
Stay tuned for updates.
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