A written narrative describing the medical reason you need orthognathic surgery to correct a problem with your jaw is the best way to get your insurance company to approve your claim.
Both dental and health insurance cover medically necessary services. However, many procedures fall into a gray area between plastic (approved) and cosmetic (declined) treatments.
Also, make sure to budget for out-of-pocket costs after your insurance pays. Every plan has expense-sharing features. Plus, choosing an out-of-network oral and maxillofacial surgeon can set you back.
Getting Insurance to Cover Orthognathic Surgery
Getting insurance to pay for orthognathic surgery means documenting the necessity in advance, and sometimes submitting the claim to both your medical and dental plan – if you have one.
However, the reason you need the operation plays a much more significant role in determining whether your plan(s) will honor the claims submitted by your provider.
Medicaid is most likely to pay for corrective jaw surgery because of its hybrid nature. Medicaid is primarily health insurance, but sometimes also covers dental work for adults.
The federal government sets up the framework, but the states determine eligibility and which benefits to provide. Two state-level Medicaid considerations are pertinent to this discussion.
- Oral and Maxillofacial Surgery is a covered benefit in twenty-seven states
- Benefits for orthodontic braces break based on patient age
- Children under the age of 21 have coverage in most states if they meet the 26-point system for a malocclusion
- Adults over the age of 21 must have a medically necessary reason unless they live in Oregon or Washington DC
Getting health insurance to cover corrective jaw surgery requires that you show the procedure is medically necessary: the service treats an illness, injury, condition, disease, or its symptoms.
Plastic surgery corrects dysfunctional areas of the body and is often medically necessary. Meanwhile, cosmetic procedures enhance appearance by improving aesthetic appeal, symmetry, and proportion and never fit the criteria.
Health insurance is more likely to pay for orthognathic operations that fall into the plastic surgery category. Some cases are a slam dunk, while others require your practice to submit a written narrative describing less invasive treatments tried and explaining why the reconstructive procedure is your only hope for a resolution.
Insurance often covers plastic surgery because it reconstructs facial and body defects caused by congenital deformities, accidents, or illnesses, as do these jaw procedures.
- Open reduction of a fractured or dislocated jaw caused by direct force trauma to the face
- Mandibulectomy to remove cysts and cancerous tumors before they metastasize and spread to other parts of your body
- Correction of significant congenital deformities such as a cleft palate, micrognathia (small mandible), or agnathia (absence of the condyloid process)
- Removal of osteonecrosis of the jaw (ONJ) to excise dead (necrotic) bone exposed in the mouth
- Operative joint procedures to address pain and dysfunction caused by Temporomandibular Joint Disorders (TMJ or TMD) or arthritis
- Operations to treat obstructive sleep apnea, which can lead to high blood pressure, headaches, stroke, and heart failure
Health insurance never approves claims for cosmetic jaw surgery costs because they are not medically necessary. Taking out a loan is one avenue to help pay for operations that improve appearance rather than address an underlying disease, injury, or dysfunctional body part.
Insurance denies claims for cosmetic surgery because it reshapes healthy tissue to improve appearance and symmetry, as do these jaw procedures.
- Asian V-line reduction to contour, shave, and reshape the lower jaw and create a streamlined profile and proportional chin
- Mandible implants to augment the chin and create a more balanced facial silhouette
- Gummy smile where the surgeon repositions the upper jaw further into the skull to reduce the visibility of gums when you show your teeth
Your dental plan may coordinate benefits with health insurance when medically necessary orthognathic surgery also requires treatment of the teeth or gums. Typically, medical is primary and dental secondary.
For example, dental coverage becomes primary when the patient needs orthodontic braces in combination with the operation.
- Expansion of the maxillary arch allows the later straightening of over-crowded teeth through orthodontia
- Orthodontic braces often bookend operations to correct tooth alignment problem such as overjet, misplaced midline, open bite, overbite, underbite, crossbite, etc.
Corrective Jaw Surgery Cost with Insurance
Your costs for corrective jaw surgery with insurance depend on the features of your plan, whether you pick an in-network provider, and if the company will honor claims for each step in the process (see below).
The amount paid by each person is impossible to determine. However, cost-sharing features and in-network discounts can help you develop an accurate estimate.
The cost-sharing features embedded in your insurance policies determine how much you must spend out-of-pocket for corrective jaw surgery. You may have two sets of unreimbursed expenses when medical and dental plans both cover portions of a maxillofacial procedure.
- Deductible: the amount paid by the patient before benefits begin
- Copayment: fee paid for each covered visit to a provider
- Co-insurance: a percentage of the allowed amount paid by the person
Keep in mind that dental coverage often includes an annual benefit maximum that limits the benefits paid towards oral care each year. You could easily exceed the upper bound with one procedure.
Also, consider the maximum out-of-pocket limit built into most medical insurance plans. The plan pays 100% of the allowed charges (see next section) associated with in-network providers after you reach this limit.
The prices charged by the practice are another significant factor affecting how much orthognathic surgery will cost with insurance. Many medical and dental plans include networks of participating providers, who agree to charge less to card-carrying members.
Look at the explanation of benefits statement from a recent claim. Three figures illustrate a crucial point about using in-network entities.
- Provider Charge: the inflated retail price
- Allowed Amount: the reduced wholesale fee
- Member Discount: the amount saved by staying in-network
Search the provider directory for your medical and dental insurance plans, and choose a surgeon on the list for both. Otherwise, you risk losing the pre-negotiated member discount – which is often 50% or more.
Furthermore, the amounts you pay to out-of-network providers do not count towards your annual limit on unreimbursed expenses. Therefore, plan accordingly and choose an oral and maxillofacial surgeon that is in-network.