Alyssa Lane
Orthognathic surgery, or jaw straightening surgery, is often not covered by medical insurance companies, who may deem it a cosmetic or dental procedure. However, orthognathic surgery may be covered by medical insurance if it is deemed medically necessary. This means that the surgery treats an illness, non-biting injury, condition, disease, or its symptoms, or is an integral part of a covered service. Some insurance companies will only cover orthognathic surgery for patients with cancer, sleep apnea, or those who have been in a car accident.
| Characteristics | Values |
|---|---|
| Orthognathic surgery covered by medical insurance | Yes, if medically necessary |
| Orthognathic surgery covered by dental insurance | No |
| Orthodontia covered by health insurance | No |
| Orthodontia covered by dental insurance | Yes, if included in the plan |
| Orthognathic surgery covered by Aetna | No, unless a speech-language pathologist has assessed the patient's speech impediment |
| Orthognathic surgery covered by Anthem-BCBS | No, unless a speech-language pathologist has assessed the patient's speech impediment |
| Orthognathic surgery covered by Cigna | No, unless a speech-language pathologist has assessed the patient's speech impedient |
| Orthognathic surgery covered by UHC | No, if the patient has mild OSAS |
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What You'll Learn
- Orthognathic surgery is covered by medical insurance, not dental insurance
- Medical necessity is crucial to getting insurance coverage
- Orthodontia may not be considered medically necessary
- Insurance companies may reject orthognathic surgery as medically unnecessary
- A letter of medical necessity from a surgeon can help get insurance coverage
Orthognathic surgery is covered by medical insurance, not dental insurance
Orthognathic surgery is a costly procedure, and whether or not it is covered by insurance depends on the insurance provider and the specific plan. While dental insurance is unlikely to cover orthognathic surgery, medical insurance may cover it if it is deemed medically necessary.
In the United States, the majority of the population (67%) relies on private insurance plans for their health services. However, the guidelines used by these insurance companies to determine coverage for orthognathic surgery have been criticised for being imprecise and inconsistent, leading to frequent denials of coverage. For example, some insurance companies may deny coverage if the surgery is deemed cosmetic, while others may approve it if it corrects an abnormal anatomy or treats a congenital deformity. As such, it is important to carefully review the specific criteria and definitions outlined in your insurance policy to determine if orthognathic surgery is covered.
To increase the likelihood of insurance coverage, it is essential to establish the medical necessity of the procedure. This typically involves demonstrating that the surgery treats an illness, non-biting injury, condition, disease, or its symptoms. For instance, orthognathic surgery may be deemed medically necessary if it is performed to correct a significant congenital deformity, restore function following an injury or tumour treatment, or address malocclusion contributing to temporomandibular (TMJ) syndrome. Obtaining a letter of medical necessity from a surgeon or dentist and submitting it to the insurance company for pre-certification can significantly strengthen the case for coverage.
While dental insurance typically covers a range of dental procedures and offers benefits such as lowered dental care costs, it is less likely to cover orthognathic surgery. This is because orthognathic surgery is often considered a medical rather than a dental matter. On the other hand, medical insurance may cover oral surgery procedures, depending on the plan, the medical health status of the individual, and the type and complexity of the surgery. Therefore, it is advisable to consult with both dental and medical insurance providers to understand the extent of coverage offered by each plan.
In summary, orthognathic surgery may be covered by medical insurance if it is deemed medically necessary according to the criteria set by the insurance company. While dental insurance is less likely to cover this type of surgery, it is worth exploring both options and understanding the specific benefits and limitations of each plan.
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Medical necessity is crucial to getting insurance coverage
Orthognathic surgery, or corrective jaw surgery, is often a costly procedure. While insurance coverage for this surgery can be complex and varied, understanding the concept of "medical necessity" is crucial to getting insurance coverage.
Medical necessity typically refers to the demonstration that the surgery is necessary to address a functional impairment or health-related issue. This could include treating an illness, non-biting injury, condition, disease, or its symptoms. For example, orthognathic surgery may be deemed medically necessary if it is required to correct a severe bite misalignment that affects eating and speech, or to restore function following treatment for a substantial accidental injury, infection, or tumour.
To determine medical necessity, you should consult with your healthcare provider, such as your dentist, oral surgeon, or other specialists. They can provide the necessary documentation and help you understand the benefits of the procedure. This documentation should be as detailed and comprehensive as possible, including medical records, diagnostic test results, images, measurements, impressions, appropriate ICD-10 and CPT codes, and the expected outcome.
Once you have the necessary documentation, you can submit it to your insurance company for pre-authorization or pre-certification. This process involves obtaining approval from the insurance provider before the surgery can be performed. By demonstrating medical necessity, you can increase your chances of getting insurance coverage for orthognathic surgery.
It is important to note that insurance coverage for orthognathic surgery can vary depending on the specific insurance plan and company. Some insurance plans that may provide coverage for this surgery include comprehensive health insurance plans and dental insurance plans. Additionally, it is worth considering that medical insurance is more likely to cover surgeries that address functional issues, while dental insurance may contribute to procedures involving the teeth or gums.
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Orthodontia may not be considered medically necessary
To establish medical necessity, a written narrative or letter from a dental or medical professional describing the reasons for the surgery may be required. This letter should include as many elements as possible to make a strong case for medical necessity. However, even with a compelling case, insurance companies may still deny coverage, as they may have different criteria for determining medical necessity.
The criteria for determining medical necessity can vary between insurance companies and policies. Some policies may consider orthodontia as a covered service if it treats an illness, injury, condition, or disease, or is deemed an integral part of a covered service. For example, the correction of significant congenital deformities, restoration of function following accidental injury or treatment for infection or tumours, or the treatment of malocclusion contributing to temporomandibular (TMJ) syndrome may be considered medically necessary by some insurance providers.
It is important to carefully review your insurance policy to understand their specific definition of medical necessity and their criteria for coverage. Shopping around for a different insurance plan may not be a feasible solution, as many insurance companies have similar exclusions for orthodontia and orthognathic surgery. Instead, it may be more effective to focus on building a strong case for medical necessity and working with your dental or medical professional to appeal any denials of coverage.
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Insurance companies may reject orthognathic surgery as medically unnecessary
Orthognathic surgery is a complex and specialised procedure, and insurance providers may consider it medically unnecessary in some cases. The decision to approve or deny coverage for orthognathic surgery depends on various factors, including the patient's specific insurance plan, the medical necessity of the procedure, and the criteria used by the insurance provider to determine coverage.
Another reason for rejection is the absence of a significant jaw deformity or demonstrable health impairment. Insurance companies may deny coverage if they determine that the patient does not have a severe enough condition that warrants surgery. In these cases, the insurance company may suggest alternative treatments or corrective measures that do not involve surgery.
Additionally, insurance providers may reject orthognathic surgery as medically unnecessary if they believe that the etiology of the condition is not a covered benefit. This means that the cause of the jaw issue may not be included in the patient's insurance plan, resulting in a denial of coverage. Furthermore, some insurance plans may have specific exclusions or limitations for orthognathic surgery, leading to a rejection of coverage.
The process of obtaining insurance coverage for orthognathic surgery can be complex and challenging. Patients often need to provide detailed documentation and undergo a thorough evaluation to demonstrate the medical necessity of the procedure. This may include submitting medical records, diagnostic test results, and a treatment plan. In some cases, a letter of medical necessity from a surgeon or dentist may be required to support the claim.
It is important for individuals considering orthognathic surgery to carefully review their insurance policies and understand the specific criteria for coverage. By understanding the requirements and potential obstacles, patients can increase their chances of successfully obtaining coverage for this costly procedure.
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A letter of medical necessity from a surgeon can help get insurance coverage
A letter of medical necessity (LOMN) is a document from your surgeon or healthcare provider that recommends a particular treatment, product, or device for medical purposes. It is often required by insurance companies to prove that a procedure is medically necessary. In the case of underbite surgery, this letter can help get insurance coverage by demonstrating that the surgery is not simply cosmetic but is necessary to treat a medical condition.
The letter of medical necessity should include relevant patient history and information about the medical necessity and expected outcome of the treatment. For underbite surgery, this could include documenting the malocclusion class with images, measurements, impressions, and appropriate ICD-10 and CPT codes. This information helps the insurance company understand the specific details of the patient's condition and the expected outcome of the surgery.
It is important to note that even with a letter of medical necessity, there is no guarantee that insurance will cover the entire cost of underbite surgery. The insurance company will review the letter and make a determination based on their own criteria and definitions of medically necessary. Additionally, the annual maximum benefit of the insurance plan may limit how much the plan pays, leaving the patient with some out-of-pocket expenses.
To increase the chances of insurance coverage, it is essential to submit the letter of medical necessity to the insurance company for pre-certification. This allows the insurance company to review the information and provide an initial indication of whether the surgery may be covered. If the insurance company denies the claim, the patient may have the right to submit an appeal, and the process may involve multiple levels of review.
In summary, a letter of medical necessity from a surgeon can be a crucial step in helping to get insurance coverage for underbite surgery. It provides the insurance company with the necessary information to understand the patient's condition and the medical necessity of the surgery. While it does not guarantee coverage, it significantly improves the odds of reimbursement for the procedure.
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Frequently asked questions
Orthognathic surgery is often covered by medical insurance, not dental insurance, when it is deemed medically necessary.
This is decided by the insurance company based on their criteria. It usually means the procedure treats an illness, non-biting injury, condition, disease, or its symptoms.
You can ask your oral surgeon to compose a letter of medical necessity to submit to the insurance company for pre-certification.
You have appeal rights, and you can ask your doctor to call the insurance company to advocate for your case. If insurance coverage is still denied, you can discuss a fixed-rate cash option with your surgeon.
Yes, you can ask your orthodontist/oral surgeon about any payment plans they offer.
