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 deemed medically necessary. This article defines terms you must know. It shows how to ask insurers to pay for care they may say no to at first.
Use the examples we provide to help your doctor compose a written narrative. Send the letter to the insurer before your dentist starts your care
Medically Necessary Dental Work
Medical insurance pays for dental work only when deemed medically necessary. However, there are many similar terms for this.
Learn the meanings behind phrases like:
- Diagnose or treat a sickness, injury, or symptom
- Suitable for the health problem
- Within normal standards of care by doctors
- Not more expensive than another service
- Part of another covered treatment
Call your insurance company for their exact language.
Covered Accidents
Dental work is medically necessary to diagnose and treat wounds resulting from non-biting accidents. Therefore, expect your medical insurance to cover procedures addressing these injuries.
- Lacerations in the mouth and gums
- Dislodged or chipped teeth
- Broken jaw bone
Paying an emergency dentist without dental insurance is much easier after accidents because your healthcare program should pay the bill.
Covered Illnesses
Dental work performed to diagnose and treat illnesses and diseases is medically necessary. Therefore, your medical insurance might cover procedures addressing these sicknesses.
- Cancers of the neck, mouth, or jaw
- Osteoporosis of the mandible or maxilla
- Infections in cheeks, tongue, or gums
- Side effects of prescription medications
Integral Part
Dental work that is integral to another covered service may be medically necessary. In these cases, your medical insurance might pay for procedures it typically does not cover, such as these examples.
- Wiring teeth when treating a jaw fracture
- Braces before and after orthognathic surgery
- Tooth extractions before cancer radiotherapy
- Imaging studies to diagnose possible pathologies
Pre-Certification
Corresponding with the issuing company before treatment is the most critical aspect of getting any dental treatment covered by medical insurance. You want the carrier to pre-authorize any procedure to minimize later claim denials.
Have your physician, not dentist, compose a letter of medical necessity and submit it to the insurance company for pre-certification. Include these elements in the document.
- SOAP Notes (Subjective, Objective, Assessment, Procedure)
- Subjective: What the patients report about their health
- Objective: Facts that can be verified or observed
- Assessment: The provider’s conclusions, diagnosis, or prognosis
- Procedure: Specific treatment that the dentist will provide
- A narrative providing the treatment rationale
Oral Surgery Coverage
Health insurance frequently covers oral surgery because most procedures are medically necessary, and their office staff have experience with medical billing codes.
Wisdom Teeth
Medical insurance sometimes covers wisdom tooth extractions performed by an oral surgeon. Some procedures are medically necessary, while others are not.
Medical insurance covers bone-impacted wisdom teeth extractions. Third molars embedded in the jaw cause pain and infection and lead to the development of cysts.
However, the impaction severity affects claims payment probabilities.
| Severity | Covered |
| Soft-Tissue Impaction | Least Likely |
| Partial Bony Impaction | More Likely |
| Complete Bony Impaction | Most Likely |
Jaw Surgery
Your medical insurance might cover specific jaw surgeries performed by an oral and maxillofacial surgeon, but not all.
Health insurance pays 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 |
Tori Removal
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.
If you have one, you may have to pay your oral surgeon out-of-pocket or bill your dental plan. Tori are benign growths that do not cause pain or lead to other medical problems if left untreated.
Major Prosthodontic Appliances
Medical insurance rarely covers prosthodontic services. A prosthodontist is a dentist specializing in replacing missing teeth, something dental plans typically address.
However, exceptions to the rule sometimes apply.
Dentures
Medical insurance rarely covers dentures, even though the ability to chew food is crucial for good health. This prosthodontic service falls neatly inside the dental care category.
However, the cost of dentures with extractions could be lower when you can establish a medically necessary reason to pull any remaining teeth. Some of these conditions might qualify.
- Dislodged teeth after an accidental non-biting injury
- Extraction of teeth before radiation to treat cancer
- Tooth loss from side effects of prescription medications
Implants
Health insurance rarely covers dental implants because they are more costly than the alternative tooth replacement option: dentures. However, your prosthodontist can make a case for specific precursors.
Medical insurance might pay for early-stage treatment steps deemed medically necessary when they diagnose or treat disease or injury.
- CT scans diagnose diseases affecting facial structures.
- Prevent further bone atrophy caused by diseases such as diabetes, digestive disorders, or osteoporosis.
- Dental ridge reconstruction after surgery to remove a cancerous tumor or reduce an accidental fracture
Periodontal Gum Disease
Medical insurance rarely covers periodontal disease, as dental insurance typically pays for gum inflammation treatment. However, patients can sometimes establish medical necessity via the integral to another covered service criteria.
Gum Treatments
Health insurance may cover several early-stage periodontal disease (gingivitis) treatments when deemed integral to another covered service. Some of these remedies might qualify.
- Antibiotics to eliminate infection
- Deep cleaning (scaling and root planing)
- Full-mouth debridement
For example, Medicare pays to eliminate an oral or dental infection before other listed procedures.
- Organ transplant
- Cardiac valve replacement
- Valvuloplasty procedures
- Treatment of cancer
- Chemotherapy
- (CAR) T-cell therapy
- High-dose bone-modifying agents
Gum Surgery
Health insurance is less likely to pay for periodontal surgeries needed to treat periodontitis, the more advanced gum disease. These procedures might fail the medically necessary test.
- Gum grafting
- Laser-Assisted New Attachment Procedure (LANAP)
- Pinhole Rejuvenation.
- Flap surgery
Each periodontal surgery has a less costly alternative to eliminate oral or dental infection: deep cleaning, full-mouth debridement, and antibiotics.
Endodontic Treatment Benefits
Health insurance rarely covers endodontic procedures because treating tissue inside your tooth is dental work. The only medically necessary service could be an antibiotic prescription to prevent the spread of infection.
Root Canal
Your medical insurance is unlikely to cover root canal therapy because removing nerves, blood vessels, and other living tissues inside the tooth is a dental procedure. It is not medically necessary.
Root canal payment plans might help patients without dental coverage. The pain can be excruciating, leaving you no choice if you want to save the tooth.
Tooth Abscess
Health insurance might pay for the least expensive part of treating an abscessed tooth. The endodontist will cut the gums to allow pus to drain and may prescribe an antibiotic to eliminate any infection that might spread throughout the body.
Your plan could honor claims for the antibiotic while denying coverage for all other steps.
Orthodontic Metal Braces
Medical insurance sometimes covers orthodontic braces for children or adults when medically necessary. However, the less costly alternative rule means metal appliances rather than Invisalign and other clear tray solutions.
Necessary Braces
Health insurance might pay for metal braces when the orthodontist can establish a medically necessary reason. However, these qualifying conditions are rare.
Apply these lessons when filing pre-certification documentation. Some of these conditions might fit the criteria.
- Reposition teeth after a non-biting accident such as a broken jaw
- Temporomandibular Joint Disorders (TMJ or TMD) bite adjustments
- Sleep apnea (when crooked teeth restrict or block airflow)
- Removal of braces to treat disease of the head, neck, or jaw
- Before radiation therapy
- Before highly stomatotic chemotherapy
- Complications of IV bisphosphonates
Correcting Malocclusions
Health insurance does not cover orthodontic braces for adults or children to straighten crooked teeth. The correction of malocclusions falls squarely into the dental category.
Monthly payment plans for braces might be a way to work around this limitation. Consumer-direct clear aligner trays offer financing and more affordable price points, a key consideration for many families.
Basic Restorative Services
Medical insurance rarely covers basic restorative dental services unless they diagnose or treat an injury, illness, or disease.
Fillings
Health insurance does not pay for fillings to correct tooth decay caused by caries. This basic restorative procedure falls squarely into the dental category with no exceptions.
Crowns
Health insurance does not pay for crowns to restore teeth weakened by decay or cracks, the most common reason for this restorative procedure.
However, your medical plan might cover crowns needed to restore chewing function after a non-biting accident damaged your teeth. File a claim with the issuing company tying treatment to the injury.
For example, I (the author) once contracted the flu, passed out, and broke my two front teeth. I required crowns to restore my smile and biting function. I might have had a valid claim of medical necessity.
If only I knew then what I know now! Now you do, too.
