Health insurance cover dental

When does 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 under the plan.

Knowledge of how your health insurance plan may interpret and apply “medical necessity, ” for each category of dental procedures, is the key to getting your claim paid. For your convenience, this article breaks down the most common specialties.

When Medical Insurance Covers Oral and Maxillofacial Surgery

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

Oral and maxillofacial surgery are serious procedures, often caused by accidents or related diseases. Therefore, your medical plan is more likely to deem many oral surgeries as medically necessary and cover the expense.

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Wisdom Teeth Removal

Your health 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.

Jaw Surgery

Your health 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. 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. Health insurance often pays for anesthesia when deemed medically necessary. General and monitored anesthesia is considered necessary when a local anesthesia is deemed ineffective. Check your policy language for a list of qualifying conditions.

When Health Insurance Covers Endodontics

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

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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.