Challenge
*Clara was working on a claim for *Michael, who was injured on the job when a ladder slipped out from under him, causing him to fall face first to the ground. A clinical and radiographic evaluation revealed significant trauma to his upper jaw, including fractures to five upper teeth, three of which were beyond repair and required extraction.
As the case was reviewed in more detail, additional challenges became clear. Michael’s remaining upper teeth were already compromised due to pre-existing conditions, including multiple missing teeth, periodontal disease, decay, and loss of alveolar bone. Because of this lack of stability, traditional tooth-supported replacement options were not viable. The provider determined that the only functional solution would be a full upper implant-supported denture, requiring extraction of the remaining teeth and placement of five implants.
At the same time, the assigned claims adjuster, Clara, was facing a complex and potentially high-cost case, with the need to ensure treatment was both medically necessary and aligned with appropriate guidelines, without delaying care or engaging in time-consuming back-and-forth with the provider.
Solution
The dentist proposed two treatment plans: an implant-retained overdenture and a significantly more expensive, high-end implant-supported bridge. The case was referred to the Careworks dental program, which provides a clinical review team supported by peer oversight from medical directors.
Using an automated patient history and guideline-triggering process, the Careworks team flagged the potential for unnecessary enhanced treatment. Upon clinical review, the team determined that the high-end bridge represented an upgrade and betterment rather than a medically necessary option and was not justified over the more cost-effective overdenture solution.
The Careworks team communicated clear, evidence-based recommendations, enabling Clara to confidently adjudicate the claim without needing to pursue a second opinion or engage in prolonged discussions with the provider.
Result
By guiding the provider back to the appropriate level of care, Careworks ensured Michael received a clinically appropriate outcome while avoiding overutilization, resulting in total cost savings of over $29,000 without compromising patient care.
Clara also benefited from a more efficient process. With Careworks’ clinical validation and clear recommendation, she avoided additional reviews, reduced administrative burden, and eliminated back-and-forth emails, allowing for faster decision-making and improved overall claims management.
*Names changed for privacy purposes