When does private health insurance cover dental work?

This is a common question asked by patients without a dental plan. Your medical plan may pay for certain oral care that it deems “medically necessary.”

The definition of “medically necessary” may include dental care arising from non-biting accidents, certain diseases, and treatments deemed integral to other services included in the plan.

Follow the five-part outline found below.

Oral and Maxillofacial Surgery and Medical Insurance

An oral and maxillofacial surgeon treats diseases, injuries, and defects of the mouth, teeth, jaws, face, head, and neck. The surgeons most commonly perform wisdom tooth extractions, bone grafting, and jaw surgery. They often administer anesthesia.

Oral and maxillofacial surgery required because of non-biting accidents or related diseases are medically necessary. Therefore, your private medical plan could cover this subset of operations and pay a portion of the expense.

Wisdom Teeth Removal

Your medical insurance plan may pay for a portion of your wisdom teeth removal. Many will pay for the surgical extraction of erupted, soft tissue impacted, and bone-impacted teeth.

Wisdom teeth that are not impacted are rarely included and require a dental plan. Many young adults need this procedure. It should not come as a surprise. Parents can make the experience more affordable by acting in advance.

Jaw Surgery

Your medical insurance plan may honor claims for jaw surgery when the need arises from a non-biting accident, disease, or defect.

Your plan will likely pay for any jaw surgery needed to correct broken bone structures caused by an accident – including bone grafting. It may also pay for orthognathic surgery needed to correct conditions not treatable through braces. Below are several examples.

  • Skeletal deformities that contribute to chewing dysfunction
  • Facial discrepancies associated with sleep apnea and other airway obstructions
  • Cleft palate causing severe speech defects

Your plan may classify certain jaw surgeries as an elective procedure, and will not pay claims. Examples include surgery to address Temporomandibular Joint Pathology (TMJ), as well as anything designed to improve one’s appearance.

Anesthesia

Your oral or jaw surgery may require anesthesia during the operation. Medical insurance often pays for anesthesia when deemed medically necessary. General and monitored anesthesia are considered necessary when a local anesthesia is deemed ineffective. Check your policy language for a list of qualifying conditions.

Prosthodontics Health Insurance Coverage

Your private health insurance plan will not cover most prosthodontist services – except when medically necessary. Your prosthodontist specializes in improving the function, comfort, and appearance. They treat and handle oral and facial problems that involve restoring missing tooth and jaw structures.

A prosthodontist is a highly trained specialist in implants, crowns, bridges, and dentures.

Dental Implants

Private health insurance rarely covers all dental implant costs as replacement teeth fall outside the scope of most policies. However, many plans could pay for several early steps. Have the practice manager submit a preauthorization request including the ICD 9 or 10 reason codes for each treatment stage.

The dental implant process has multiple stages. It is not a single treatment. Some of the earlier services are more likely to be medically necessary that later-stage steps.

  1. CAT scans to measure bone density and structural anomalies: maybe
  2. Tooth extractions due to an accident or disease-related condition: see oral surgery
  3. Bone grafting after an accident or related to a bodily disease: yes
  4. Surgical placement of the implant body into the jaw: often yes
  5. Surgical insertion of the abutment: rarely
  6. Implant supported crowns, bridges, dentures: rarely

Dentures & Crowns

Most health insurance policies will not cover dentures, bridges, or crowns. These tooth replacement and restoration options fall outside the scope most policies. They fall are primarily cosmetic in nature although they restore function.

  1. Dentures are removable appliances that can replace missing teeth
  2. Bridges are fixed prosthesis that spans a gap in your smile
  3. Crowns are caps over a tooth to restore shape, size, and strength

Orthodontic Braces Paid by Medical Insurance

Orthodontics is a specialty that deals with correcting irregularities in tooth placement and alignment. Your orthodontists most frequently will recommend a specific type of braces to straighten your teeth and improve your smile and self-confidence. In most cases, this is not medically necessary. Private medical plans rarely cover orthodontia.

Dental insurance covering braces can reduce long-term costs.

Accidents and Cleft Malocclusions

Your medical insurance plan may pay for orthodontia to correct a condition caused by an accident, or when the patient has a malocclusion. This includes braces to reposition teeth after a non-biting accident. It also includes braces to correct a malocclusion caused by a cleft palate.

Metal Braces and Invisalign

Orthodontists primarily treat teenage children with the primary need to improve smiles and self-confidence. He or she may recommend metal braces, Invisalign, and retainers to achieve the desired look. Medical insurance will not honor claims for orthodontia to address these basic needs.

Supplemental dental programs cover braces. You may find that purchasing a policy your oldest child is ten years old is the best way to manage these expenses.

Braces for TMJ

It will be very difficult to get a medical plan to pay for orthodontic braces to correct TMJ (temporomandibular joint disorder). While the disorder meets many of the criteria for “medically necessary”, the treatment is controversial. Braces for TMJ do not work very well and often cause the problem to worsen. There is no clear benefit to the patient.

Endodontics Paid by Health Insurance

Endodontics is a specialty area of dentistry that focuses on treating the internal structure of teeth including the pulp and nerves. Your health plan may sometimes cover traumatic dental injuries treated by your endodontist, but rarely for root canals.

Dental plans with high annual maximums can help patients needing major work over time.

Traumatic Injuries

Endodontists specialize in handling traumatic injuries and other emergencies: accidents and sports-related injuries that cause damage. As the result of an accident, your teeth may be fractured, chipped, dislodged (Luxated), or knocked out (Avulsed).

Most health insurance plans will pay for non-biting accidents. Non-biting accidents could trigger payable claims to remove, repair, replace, restore, or reposition natural teeth and/or bodily tissues of the mouth. This includes X-rays to diagnose possible fractures.

Root Canals

Your endodontist may recommend a root canal if the pulp in your tooth becomes inflamed or infected. Left untreated, this condition may lead to an abscess. An abscessed tooth has a pocket of infection around the root.

Health insurance will not honor claims for the root canal work, but it may pay for any antibiotics needed to clear up any infection. File a claim with your carrier for this portion of the expense.

Basic Dental Work Covered by Medical Insurance

Private medical plans rarely cover any other form of dental work. The remaining procedures not previously addressed do not fit the definition of medical necessity very well. This holds true for general, cosmetic, and periodontics.

Supplemental and secondary dental plans can offset costs for basic oral care.

Periodontics

Periodontists focus on treating infections of the gums and teeth. Since infections can spread to other parts of the body, medical insurance may sometimes pay for the periodontal examination and treatment if the patient is undergoing a different surgical procedure included in the plan.

The coverage for periodontal disease will not extend to gum grafting, where your periodontist takes tissue from the roof of your mouth, and grafts it over exposed roots, or to replace diseased gums.

Cosmetic Dentistry

Medical insurance will never honor claims for any cosmetic dentistry. Cosmetic treatments improve the appearance of your teeth, mouth, and smile. You will have to pay out-of-pocket for bonding, porcelain veneers, lumineers, whitening and bleaching, contouring and shaping.

Some dental plans cover cosmetic procedures after a waiting period through an optional rider.

General Dentistry

Medical insurance does not pay for most forms of general dentistry including routine checkups, cleanings, fillings, sealants, and X-rays to detect caries. However, many dental plans cover preventive oral care with no waiting periods. 

The one exception to this rule is private plans purchased through your state exchange. Under Obamacare, plans must include dental coverage for children. Some carriers may combine the benefits into a single plan while others will issue separate policies.

Medicaid covers comprehensive dental care in 32 states. Comprehensive care can mean preventive, restorative, and periodontal care. However, each state has unique rules and eligibility requirements.

Further Reading

Posted