An oral and maxillofacial surgeon treats diseases, injuries, and defects of the mouth, teeth, jaws, face, head, and neck.
While each of these body parts is critical to your overall health, medical insurance does not always cover every service or cost. Meanwhile, dental plans include more procedures, but with an annual benefit maximum.
Health insurance pays for oral surgery as the primary payer with no yearly maximum (when it covers a procedure). Then, the dental coverage (if you have it already in force) coordinates benefits as the secondary payer.
The trick is getting both types to coverage to honor claims when the line between the two becomes blurry – which happens often.
When Dental Covers Oral Surgery
Dental insurance covers oral and maxillofacial surgery – if you have a policy in force months before the need arises. For patients with both types of coverage, the two will often coordinate benefits – meaning the two pay for different parts of the provider charges.
- Dental is secondary to health insurance when the procedure is medically necessary. The second plan might fill in the deductible and extra fees from out-of-network surgeons.
- Dental is primary when the procedure is not medically necessary or integral to a covered service under medical insurance.
- Gum erupted wisdom tooth extractions
- Apicoectomy (retrograde root canal treatment)
- Bone grafting
- Implant body placement
- Vestibuloplasty (ridge extension)
Attempting to buy a new dental insurance policy with instant benefits for oral surgery is unlikely to prove cost-effective for the first stage procedures. Most plans have features that discourage patients from starting coverage, filing expensive claims right away, and then canceling after the work is complete.
Expect a new dental program to include some combination of these exclusions.
- Six to twelve month waiting periods for major services
- No waiting periods and immediate coverage with caveats
- Graded benefits (low reimbursement levels in the early years)
- Large deductibles paid by the patient before claim payments start
On the other hand, patients in the queue for oral surgery often have needs for later dental work that takes place after the gums and jawbone heal. While a new plan may not cover the operation in full, it could be in high gear once you are ready for implants, dentures, or orthodontia.
Medicaid is primarily health insurance for low-income families. However, this tax-payer funded program also covers certain types of dental work in twenty-five states.
The federal government establishes the parameters for Medicaid. Then, each state makes decisions about how to run the program, including the income levels needed to qualify, and the kind of services it covers.
Medicaid pays for oral surgery in twenty-four states. If you are fortunate to live in one of these areas, your program could pay for some of the operative procedures that do not fit the medically necessary criteria (see above).
When Medical Covers Oral Surgery
Most medical insurance policies do not cover dental work even though your mouth is crucial to your overall wellbeing. Most plans exclude payments for the routine care, treatment, and replacement of teeth and related tooth structures such as your gums and jawbone.
However, medically necessary treatment is the exception to this general rule. Fortunately, and oral and maxillofacial surgery is more likely to meet the criteria than general dental care.
Necessary or Integral
Most medical insurance plans typically cover oral surgery with no annual maximum when the procedure falls into one of two categories. Therefore, have the practice write a precertification narrative describing how the treatment meets both of these definitions.
- Medically necessary: the service treats an illness, non-biting injury, condition, disease, or its symptoms
- Incident to and an integral part of a covered service: part of the physician’s diagnosis or treatment of a non-biting accident or illness
Many operative procedures fit neatly into at least one of these categories. Use these examples when developing your precertification to sharpen the narrative.
- Extraction of wisdom teeth
- Bone impacted: most likely
- Gum (soft tissue) impacted: less likely
- Non-impacted: rarely
- Repair of cleft-palate and other congenital abnormalities
- Removal of teeth before radiation therapy of the head and neck
- Excision of cysts or tumors of the jaws or facial bones
- Reconstruction following surgical procedures for cancer
- Reduction of facial bone fractures
- Removal of broken teeth necessary to reduce a jaw fracture
- Dental services following non-biting accidents
- Treat natural teeth damaged, lost, or removed
- Orthodontic therapy to correct misalignment
- Installing the first denture, crown, or fixed bridgework
- General anesthesia when local will not provide a successful result
- Jaw surgery to correct sleep apnea or Temporomandibular Joint Disorders (TMJ)
Medicare is the primary form of health insurance for seniors over the age of 65, and many disabled individuals under retirement age. As above, Medicare could pay for oral surgery when medically necessary or when the service is an integral part of a covered procedure.
The federal government provides two crisp examples of when Medicare covers oral surgery. Other operative procedures fall into a gray area and may require skillfully crafted narratives from your practice manager.
- The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease
- Reconstruction of the jaw following an accidental injury
Also, Medicare Advantage (Part C) often includes dental care, expanding payment options for elderly patients who chose this option in the past. If not, you can switch into an Advantage plan for the extra benefits. However, you may have to wait for the annual open enrollment to take advantage.
People asking whether their Blue Cross Blue Shield (BCBS) medical insurance covers oral surgery should follow the guidelines noted above. More importantly, patients should contact the issuing company for precise answers.
BCBS is a national federation of affiliated companies using this trade name. In turn, each BCBS company issues multiple plans with unique benefits. Then, each policy has its own rules regarding which claims to honor or decline.
Therefore, do not search online for your answer. Instead, call the phone number on the back of your BCBS membership card and speak to customer service. Or, log into your member portal and read through your policy document for details.
 Aetna Medical Clinical Policy Bulletin Number: 0082