Needing oral surgery can be stressful, but an even bigger concern is how to pay for it. While oral surgeons often work with dental insurance, what about medical insurance? In some cases, procedures may be covered, but the rules can be confusing. So, when does medical insurance apply, and how can you ensure you get the most coverage possible? Let’s break down what you need to know.
Find out if your insurance is accepted by Oral Surgeons in Forest Hills, NY.
What Medical Insurance Plans Do Oral Surgeons Accept?
Oral surgeons accept medical and dental insurance plans, but the coverage depends completely on the procedure and provider. Comprehending what is covered can help you avoid unexpected costs.
Medical vs. Dental Insurance
- Medical insurance covers medically necessary surgeries, such as:
- Tumor removal
- Facial trauma repair
- Jaw abnormalities
- Dental insurance covers routine oral surgeries, including:
- Extractions and root canals
- Wisdom teeth removal (varies by plan)
- Bone grafting and implants (often limited coverage)
Private Health Insurance Plans
Private health insurance may cover oral surgery, but coverage depends on whether the procedure is considered a medical necessity or a dental procedure. Comprehending how different plans classify oral health services is essential when selecting insurance.
Medical vs. Dental Insurance for Oral Surgery
Most private medical insurance plans cover oral surgery if it is deemed medically necessary, such as:
- Biopsies, tumor removal, and reconstructive surgery related to medical conditions.
- Emergency oral procedures due to trauma, such as jaw reconstruction after an accident.
- Treatment for underlying conditions, including severe infections, congenital defects, and sleep apnea surgery.
Dental insurance, on the other hand, typically covers routine or elective procedures, such as wisdom tooth extractions (unless medically necessary) and dental implants. Many plans include annual coverage limits, deductibles, and waiting periods for major procedures, so reviewing your policy details is essential.
Medicare
Medicare provides limited coverage for oral surgery, primarily when it is medically necessary rather than routine dental care. Original Medicare (Part A and Part B) generally does not cover extractions, fillings, or dentures unless they are part of a medically required treatment. However, there are exceptions where Medicare covers oral surgery under specific circumstances.
When Does Medicare Cover Oral Surgery?
Medicare may cover oral surgery if it is required to treat a medical condition or ensure the success of another covered procedure, such as:
- Pre-surgical oral exams before a kidney transplant or heart valve replacement.
- Jaw or facial surgery due to fractures or trauma.
- Ridge reconstruction after a tumor removal affecting the jaw.
- Tooth extractions necessary for radiation therapy for oral cancer or jaw-related diseases.
- Hospitalization for dental procedures if a health-threatening condition requires medical observation.
Even in these cases, Medicare generally covers hospitalization and medical care, but not the dental procedure itself (such as extractions or implants). Patients may still have to pay out-of-pocket for the dental portion of the treatment.
Medicare Advantage (Part C) and Oral Surgery
Medicare Advantage (MA) plans often provide additional dental benefits, including coverage for oral surgery. While coverage varies, many plans include:
- Preventive care (cleanings, exams, X-rays).
- Basic dental procedures (extractions, fillings, root canals).
- Major dental work (oral surgery, dentures, implants in some cases).
Medicaid
Medicaid provides essential health coverage to millions of Americans, but dental benefits vary by state, especially for oral surgery. While Medicaid must provide comprehensive dental care for children under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, adult coverage is optional and determined by each state’s Medicaid program.
Oral Surgery Under Medicaid
Medicaid typically covers oral surgeries deemed medically necessary, including:
- Tooth extractions due to infection, trauma, or severe decay.
- Removal of impacted wisdom teeth.
- Treatment for oral and maxillofacial injuries.
- Surgery for jaw or facial abnormalities.
- Procedures required before medical treatments like organ transplants or cancer therapy.
Nevertheless, cosmetic or elective procedures—such as dental implants—are generally not covered unless they are essential for function and overall health. Since coverage rules vary by state, it’s important to check local Medicaid guidelines to understand specific oral surgery benefits available in your area.
Navigating Your Coverage Options
Knowing your insurance coverage for oral surgery is essential to avoid unexpected costs. Coverage depends on whether the procedure is considered medically necessary and whether it falls under medical or dental insurance.
Medical vs. Dental Insurance: What’s Covered?
- Medical Insurance covers surgeries deemed medically necessary, such as jaw realignment, cyst or tumor removal, and facial trauma repair.
- Dental Insurance typically covers routine and major dental procedures, including extractions, root canals, and implants, but may exclude medically necessary surgeries.
Factors Affecting Coverage
- Medical Necessity – Insurers may require proof that the procedure is essential for health.
- Pre-Approval Requirements – Many providers need pre-authorization before covering costs.
- In-Network vs. Out-of-Network Providers – Using an in-network surgeon lowers out-of-pocket expenses.
- Policy Limits & Deductibles – Check for coverage caps, co-pays, and deductibles that impact costs.
Examples of Covered vs. Non-Covered Procedures
Typically Covered by Medical Insurance:
- Jaw surgeries for severe misalignment.
- Cyst/tumor removal affecting health.
- Emergency facial trauma surgery.
Typically Covered by Dental Insurance:
- Wisdom tooth extractions (coverage varies).
- Dental implants (partially covered, may have limits).
- Root canals and crowns.
Maximizing Your Coverage
- Consult Your Insurance Provider – Confirm coverage details before surgery.
- Get a Referral – Some insurers require a dentist or physician referral.
- Submit Proper Documentation – Provide medical records, X-rays, and treatment plans for approval.
With an increasing focus on oral health and overall health connections, some insurers now offer combined medical and dental plans, improving coverage for oral surgeries. Checking your policy details can help you make the best financial decision for your treatment.
Sources.
Borrell, L. N., Reynolds, J. C., Fleming, E., & Shah, P. D. (2023). Access to dental insurance and oral health inequities in the United States. Community dentistry and oral epidemiology, 51(4), 615-620.
Gupta, N., & Vujicic, M. (2019). Main barriers to getting needed dental care all relate to affordability. Health Policy Institute Research Brief. American Dental Association.