What dental procedures might your medical insurance cover? Many patients ask this question because they do not have a dental plan and need help paying for treatment.
Your healthcare policy may pay for specific dental work that it deems medically necessary: care arising from non-biting accidents, certain diseases, and treatments considered integral to other services included in the plan.
Dental implants, orthodontic braces, and oral surgeries such as wisdom tooth extractions and some jaw operations sometimes fit the definition.
However, most oral care does not qualify unless you have an infection resulting from a root canal or periodontal disease or need anesthesia for pain.
Medically Necessary Dental Services
Health insurance will cover specific dental procedures when medically necessary, which is always a judgment call made by the claims adjuster.
- Financial assistance programs offer low-cost oral care
- Monthly payment plans can reduce upfront costs
The definition may include dental care arising from non-biting accidents, certain diseases, and treatments deemed integral to other services included in the plan.
Your health insurance might pay for medically necessary dental implants, which are appropriate to evaluating and treating a disease, condition, illness, or injury and is consistent with the applicable standard of care.
For example, included implants could involve replacing teeth lost during a covered accident or illness.
- Dislodged teeth after an accidental non-biting injury
- Extraction of teeth before radiation to treat cancer
Your health insurance might pay for medically necessary orthodontia when the braces prevent, diagnose, or treats an injury, disease, or symptoms.
The definition for included braces can vary based on the age of the individual requiring treatment and the procedure step.
- Children: to treat congenital deformities such as cleft lip or palate
- Adults: to treat diseases such as TMJ or sleep apnea
- Removal: before radiation and chemotherapy
Oral Surgery Covered by Medical
Your medical insurance could pay for oral surgery when medically necessary, often the case with this category of dental procedures.
When you have both coverage types, the healthcare component will be primary, and the dental plan will coordinate benefits as secondary.
Your health insurance should cover the cost of impacted wisdom tooth removal because the procedure is often medically necessary. Third molars can cause pain, infection and lead to the development of cysts.
However, the classification of wisdom teeth removed by your oral surgeon affects the possible claim payments.
|Soft-Tissue Impaction||Less Likely|
|Partial Bony Impaction||More Likely|
|Complete Bony Impaction||Most Likely|
Your medical insurance might cover corrective (Orthognathic) jaw surgery when medically necessary; the operative procedure treats an illness, injury, condition, disease, or its symptoms.
Oral surgeons can perform operations on your jaw for many different reasons, and some fit the coverage criteria exactly, not at all, and somewhere in between.
|Most Likely||Gray Area||Least Likely|
|Open reduction of a fractured jaw||Temporomandibular joint disorders||Asian V-line reduction|
|Mandibulectomy to remove cysts and cancerous tumors||Operations to treat obstructive sleep apnea||Mandible implants|
|Correction of significant congenital deformities||Gummy smile correction|
Your health insurance is unlikely to pay for Tori removal (torus palatinus or torus mandibularis) because the excision of excess bone on your upper or lower jaw is rarely medically necessary.
You may have to pay your oral surgeon out-of-pocket or bill your dental plan – if you have one. Tori are benign growths that do not cause pain or lead to other medical problems if left untreated.
Dental Partially Covered by Medical
Medical insurance does not cover most dental procedures even though your mouth and teeth are critical components of your body. However, some portions of treatments performed by dentists are medically necessary.
Your health insurance is unlikely to pay for periodontal disease because your gums’ treatment does not fit into the medical category. However, several elements of gum disease blur the lines and could lead to honored claims.
- Infections in the gum correlate with heart problems and diabetes. Therefore, medical insurance may sometimes pay for the periodontal examination and treatment if the patient is undergoing a different surgical procedure included in the plan.
- Gum grafting is a painful surgical procedure for advanced periodontitis. Therefore, medical insurance might cover anesthesia for patients that require deep sedation.
Your health insurance is unlikely to cover root canal therapy because removing nerves, blood vessels, and other living tissues from inside the tooth does not fit into the medical category.
However, an endodontist is likely to perform a root canal when the tooth pulp is infected or has progressed to an abyss (a pocket of puss caused by bacteria) and may prescribe an antibiotic. Your medical insurance could honor claims for the antibiotic needed after your root canal to prevent the infection from spreading to other parts of your body.