The Truth About Optional Services: It’s Not Just About Aesthetics

The term “optional” is often seen as a code word for “cosmetic” or “elective” procedures. Yet oftentimes, the services labeled optional by insurance payors are actually the very treatments that prevent pain, save patients money on future repairs, and keep natural teeth intact for a lifetime. The truth is, dental insurance was never designed to pay 100% of all treatment costs. These defined benefit plans are a financial tool designed to cover the basics, not a blueprint for achieving a patient’s best possible dental health. 

So what do we mean when we tell a patient their insurance might not cover a procedure?

It’s not unusual for a patient’s treatment needs to be met in a variety of different ways. For example, a patient could achieve the outcome of replacing a missing tooth with a removable partial denture, a fixed partial denture (bridge), or even an implant. Insurance payors refer to these as alternate or optional services. To better understand the answer to the question above, we need to dive deeper into the difference between these. 

An alternate service is best described as any other viable treatment modality that is covered under the member’s specific plan design. Many times payors will remap the reimbursement for a service based on one of the following:

1. An Alternate Benefit Plan (ABP) is a provision that means the payor or plan administrator has the right to remap the submitted service to a benefit equivalent to that of the lower-cost alternative service.
2. A Least Expensive Alternative Treatment (LEAT) clause is a plan provision that allows the payor or plan administrator the right to change the reimbursement for a service to the least expensive, clinically acceptable, alternative treatment.

Think of dental insurance less like coverage and more like a gift card with fine print. Imagine you’re at the grocery store with a gift card for ketchup, but the fine print says it only covers the price of the generic, store-brand, $2 ketchup. If you want the name-brand stuff, the gift card still works, but it only pays for that first $2; the difference comes out of your pocket. That’s exactly how ABP and LEAT function in dentistry. If the dentist recommends a higher-quality option, the insurance plan doesn’t become invalid; it just limits the amount of coverage. Any difference between what’s recommended and what the plan allows is shifted directly to the patient. 

An optional service is best described as another viable treatment modality that is not covered under the member’s specific plan design. Note: For fully insured plans in states without non-covered benefit legislation and self-funded plans, you can still be limited on what you charge for the very service(s) the payor is refusing to cover. 

When patients ask why their insurance “won’t cover” a treatment you recommended, ABP and LEAT are almost always the fine print doing the talking. This causes the payor to change – or remap – the service to reimburse at a lower rate. However, when a plan has a provision for optional services, you may be able to collect the difference between the ABP/LEAT amount and your full practice fee from the patient.

Reminding patients that reimbursement rates are simply a financial contract with the payor, not a clinical recommendation, is imperative. To maintain the highest standard of care, we must separate the conversation of benefits from the conversation of health. 

Before you begin an optional service, call and speak to the PPO’s benefits representative. 

Every plan has its own set of exclusions and limitations that determine whether or not a service is covered. Confirming those details upfront is a great way to be sure where the coverage stands. Our role is to provide a transparent breakdown of the diagnosis, the pros and cons of each treatment option, and the true cost of inaction on the patient’s part. This ensures the patient makes an informed decision based on outcomes rather than what insurance will pay for. A list of questions to have on hand when speaking with the insurance company can be found in the “Optional Services, ABP, and LEAT Plans” chapter of Dental Administration With Confidence.

Report the CDT code that most accurately reflects the services provided.

Just because a plan reimburses at a lower rate – or not at all – doesn’t mean the clinical integrity should shift. Don’t let restrictive PPO fee schedules and exclusions cap the quality of your dentistry. When you offer optional services, you open the door for patients to invest in their own health. Whether it’s choosing a more esthetic material or an advanced surgical technique, these “upgraded” options give the patient a choice in their care.

Let’s face it – we’ve all felt that internal sigh when a patient asks, “Why isn’t this covered if I need it?” When we offer optional services and stand by our clinical standards, we become true healthcare advocates. A reimbursement limit should never get in the way of clinical expertise. Embrace optional services and educate your patients; present the options, explain the why, and let the patient choose the level of health they want to invest in for themself.

Source:

Practice Booster (2026). Dental Administration with Confidence (pp. 73-76). 2025 eAssist Publishing, LLC.