Principal Periapical X-Ray Challenge

Frustration grew this year after Principal Insurance issued a letter changing requirements for periapical X‑rays, citing updated ADA recommendations. If you missed it, the letter announced reduced benefits and increased documentation requirements for these X‑rays.

Let's delve into the truth behind this clear misdirection of facts.

Did the ADA change x-ray recommendations?

Yes, but the change is almost completely centered around CBCTs, which had minimal recommendations prior. There were no major changes to routine x-ray recommendations.

So why is insurance claiming these changes are based on these recommendations?

Do I really have to explain—again—that insurance companies often “doctor” the facts?

We’ve seen this when insurers deny cases and make policy changes. They withhold or distort reality to make their policies appear more favorable to the employers and employees who purchase them than they truly are.

“Free cleaning” is the original—and still the most striking—example of marketing spin. Nothing is free. Even a “100% covered” cleaning isn’t fully accurate, as it only covers 100% of UCR, not the provider’s full fee.

Over time, insurance companies have steadily reduced benefits for periapicals by reclassifying them as Basic, adding deductibles, imposing additional restrictions and documentation requirements, and setting maximum limits.

This year is no different. Principal's latest letter saying they are reducing benefits due to ADA changes is another in a line of marketing “spin.”  The ADA recommendations did not change in a way that would justify this change in coverage.  

The change in coverage was because they wanted a way to save money, and make more profit off the backs of patients and dentists. And instead of taking the heat themselves, they found a way to “misdirect” attention toward another scapegoat.

Granted, the ADA is a large organization, and not everyone will agree with every decision it makes. Their still-uncorrected misstatements regarding screw‑ versus cement‑retained crowns highlight a lack of adequate oversight. It’s also disappointing that their response to Principal so far reflects a limited understanding of the scope of this issue.

That said, the ADA is not to blame in this instance. This is an example of an insurance company attempting to increase profit margins. To their credit, the misdirection has been effective. Don’t let insurance marketing distract you from the real issue—the insurer itself and its prioritization of profits over patient care.

Moving Forward

If you read Principal’s misdirection letter carefully, they’re asking providers to justify why a periapical X‑ray was taken. Recognize this for what it is—a delaying tactic. The patient has coverage, and payment will eventually be made. These added hurdles exist because delays, complaints, and arguments distract teams from the far easier path: getting paid.

So what do we do? Be proactive. Prepare a set of pre‑written narratives that clearly explain the most common reasons you take periapicals, and keep them ready for use with insurance companies that create unnecessary obstacles. Don’t wait for a denial to submit an appeal—that only adds more work. Include your narrative remarks with the original claim.

To be clear, this isn’t a defense of insurance companies. It’s an acknowledgment that we need our own counter‑tactics. Anticipating these issues and adopting practical, “in‑the‑trenches” solutions is far more effective, and far less exhausting, than complaining after the fact.

Dental Insurance Guy Members: Check the tools section for a list of pre-written narratives to help you get started.