Orlando Harmon
Wisdom teeth removal is considered oral surgery, and the coverage provided by Aetna for this procedure depends on the specific plan and its terms and conditions. Aetna offers a range of dental plans, including PPO and HMO options, with varying levels of coverage for oral surgery and dental procedures. Some plans may provide coverage for wisdom teeth removal, while others may not. It is important to carefully review the details of your specific Aetna plan to understand what is covered and what is not. Additionally, pre-treatment estimates and clinical reviews are available to help determine coverage eligibility.
| Characteristics | Values |
|---|---|
| Plan | Each main plan type has subtypes with 2-5 tiers of coverage. |
| Coverage | Aetna medical insurance may cover wisdom teeth removal depending on the type of plan and whether the procedure is classified as Dental in Nature (DIN) or Medical in Nature (MIN). |
| Pre-treatment estimate | You or your dentist can send a request for a pre-treatment estimate to determine if and how your plan covers the procedure. |
| Oral Surgery Center | Aetna has a specialized Oral Surgery Center that handles all variations of oral surgery claims, including dental and medical. |
| Oral and Maxillofacial Surgery Patient Management team | This team consists of board-certified oral and maxillofacial surgeons and nurses who review surgical requests and provide precertification for oral and maxillofacial surgery. |
| Clinical Policy Bulletins (CPBs) | CPBs define Aetna's clinical policy, but medical necessity determinations are made on a case-by-case basis. |
| Applied Behavior Analysis (ABA) Medical Necessity Guide | The ABA guide helps determine appropriate levels and types of care for patients with behavioral health conditions. |
| Referrals | Referrals are not required for oral surgery services covered under Aetna medical. |
| Clinical review | Some oral surgery services may require clinical review. |
| Preventive oral care | Preventive oral care is fully covered with no out-of-pocket expenses under the Aetna Dental PPO plan. |
| Coverage for simple extractions | Aetna Dental plans typically cover an estimated 20%-50% of simple extractions with a 6-month waiting period. |
| Coverage for oral surgeries | Aetna Dental plans typically provide an estimated 50%-70% coverage for oral surgeries like wisdom tooth extraction. |
| Coverage for basic dental services | Aetna Dental Direct Preferred PPO covers an estimated 20% of basic dental services, while the Direct Core PPO plan offers an estimated 50% coverage. |
| Coverage for major dental services | Major dental services like root canals, crowns, and dentures are estimated to be 50% covered with a 12-month waiting period. |
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What You'll Learn
Wisdom teeth removal is considered oral surgery
Whether or not wisdom teeth removal is considered oral surgery depends on the patient's situation. If the wisdom teeth have already erupted, a simple extraction may be performed by a dentist using local anesthesia to numb the tooth and special tools to lift and extract the tooth from its socket.
However, if the wisdom teeth are stuck beneath the gum line, partially erupted, or impacted, the help of an oral surgeon may be required. In this case, the procedure is typically considered oral surgery. Oral surgery for wisdom teeth removal involves making an incision along the gums to extract the teeth, and the patient is usually put under IV sedation.
Aetna's medical plans generally exclude dental services for the routine care, treatment, or replacement of teeth. However, some Aetna medical plans provide coverage for certain "dental-in-nature" oral and maxillofacial surgery (OMS) services related to the jaw or facial bones. For example, standard HMO plans cover the removal of tumors and cysts in the jaws or facial bones, while standard traditional plans cover the surgical removal of erupted, soft tissue impacted, and bone-impacted teeth.
To determine if wisdom teeth removal is covered by Aetna, individuals should first find out if the treatment will be covered under their medical or dental benefits plan. They can do this by sending a request for a pre-treatment estimate, after which Aetna will inform them if and how their plan covers the suggested care.
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Aetna dental plans cover 50-70% of oral surgeries
The amount and type of coverage you have for oral surgery, including wisdom teeth removal, will depend on your specific Aetna plan.
Aetna dental plans typically provide coverage of between 50% and 70% for oral surgeries like wisdom tooth extraction. However, it's important to note that there may be a waiting period for this type of surgery, and the specific coverage may vary depending on your plan. To determine your coverage, you can refer to the benefits section of your insurance policy, which will outline the conditions under which wisdom teeth removal will be covered and the rates of coverage.
Wisdom teeth removal is generally considered an oral surgery procedure. In some cases, it may be classified as a "dental-in-nature" oral and maxillofacial surgery (OMS) service, particularly if it is related to the jaw or facial bones. Aetna medical plans may provide coverage for some of these dental-related services. For example, standard HMO and traditional plans typically cover the removal of tumors, treatment of dislocations, and facial and oral wounds/lacerations in the jaw or facial bone area. Additionally, the removal of bone-impacted teeth may be covered under some Aetna medical plans, specifically standard traditional plans.
It's worth noting that some procedures, such as routine care, treatment, or replacement of teeth, are generally excluded from coverage under Aetna's medical plans. This includes services like root canals, fillings, crowns, bridges, and dental prophylaxis. However, there may be limited circumstances where these services are covered, especially if they are deemed medically necessary. For example, the extraction of teeth prior to radiation therapy of the head and neck may be covered by Aetna's medical plans.
To determine your specific coverage for wisdom teeth removal, it is recommended to review your insurance policy carefully or contact Aetna directly to discuss your plan's benefits and limitations.
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Some Aetna medical plans cover oral surgeries
Whether your Aetna medical insurance covers wisdom teeth removal depends on your specific plan. Some Aetna medical plans cover oral surgeries, while others do not.
Aetna medical plans cover oral and maxillofacial surgery (OMS) services related to the jaw or facial bones. For example, the reduction of facial bone fractures is covered under all Aetna medical plans. Standard HMO and traditional plans cover the removal of tumors, treatment of dislocations, facial and oral wounds/lacerations, and removal of cysts or tumors of the jaws or facial bones, or other diseased tissues.
Standard HMO-based plans cover the removal of partly or completely bone-impacted teeth. Standard traditional plans cover the surgical removal of erupted teeth, soft tissue impacted teeth, and bone-impacted teeth.
Aetna Dental PPO insurance covers an estimated 20%-50% of simple extractions with a 6-month waiting period. There is no waiting period for basic dental services like simple tooth extractions if all enrolled family members had dental coverage within the past 90 days of enrollment. For oral surgeries like wisdom tooth extraction, Aetna dental plans typically provide a coverage of between an estimated 50% and 70%.
To determine whether your treatment will be covered, you or your dentist can send a request for a pre-treatment estimate (predetermination). You will then be informed if and how your plan covers the care suggested. You will be reimbursed under the plan in which the oral surgery procedures are considered covered services.
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Pre-treatment estimates are available
Aetna offers pre-treatment estimates to its customers. You or your dentist can send a request for a pre-treatment estimate (also known as a predetermination). This will let you know if and how your plan covers the care suggested.
To do this, you will first need to determine whether the procedure is classified as Dental in Nature (DIN) or Medical in Nature (MIN). You can click on the links provided by Aetna to find a list of DIN and MIN procedures. Once you have determined whether the procedure is DIN or MIN, you can refer to the relevant chart to see if the procedure is covered and, if so, whether it is a medical or dental expense.
It is important to note that the type of plan you have will determine whether a procedure is covered. Each main plan type has more than one subtype, and each subtype has a different number of tiers of coverage. The chart provided by Aetna represents information for standard Aetna plans.
If you are unsure about whether your treatment will be covered, you can call Member Services at the number listed on your ID card. They will be able to provide you with more specific information about your plan and coverage.
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Members can appeal coverage decisions
As a valued Aetna member, you have the right to make your voice heard about your health care experience, whether it's about your plan, a health service, or a provider. If you disagree with a coverage determination, you can appeal the decision.
Aetna's Clinical Policy Bulletins (CPBs) define the company's clinical policy, but medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. If a member disagrees with a coverage determination, they can appeal the decision and may also request an independent external review of coverage denials based on medical necessity. This external review is available when the service or supply in question for which the member is financially responsible is $500 or greater. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA plans.
The five-character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), which is copyrighted by the American Medical Association (AMA). The codes help determine whether a procedure is classified as Dental in Nature (DIN) or Medical in Nature (MIN).
To initiate the appeals process, members can refer to the Dental Office Guide for Dental DMO protocols. Additionally, some oral surgery services require clinical review, and members can refer to the claim attachment guidelines for details on required diagnostics.
It's important to note that Aetna's conclusion that a particular service or supply is medically necessary does not guarantee that it will be covered or paid for by the company. Your benefits plan ultimately determines coverage, and some plans may exclude coverage for services that Aetna considers medically necessary. In the case of a discrepancy between Aetna's policy and a member's plan of benefits, the benefits plan will take precedence.
Members can also refer to the Applied Behavior Analysis (ABA) Medical Necessity Guide to understand the appropriate levels and types of care for behavioral health conditions. However, the ABA Medical Necessity Guide does not constitute medical advice, and treating providers are responsible for medical advice and treatment decisions.
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Frequently asked questions
Wisdom teeth removal is considered oral surgery. Aetna dental plans typically provide coverage of between 50% and 70% for oral surgeries.
Each main plan type has more than one subtype, and each subtype has a different number of tiers of coverage. You can determine whether a drug is covered by your plan by using the search tool on the Aetna website.
You or your dentist can send a request for a pre-treatment estimate. You will be reimbursed under your plan if the oral surgery procedure is considered a covered service.
In the event that a member disagrees with a coverage determination, they can appeal the decision. Members may also have the opportunity for an independent external review of coverage denials.
