Paul Sanchez
Oral surgeries can be very expensive, so it is important to know how your insurance can help with the cost. Whether or not your medical insurance covers a dental-related procedure will depend on your insurance provider and plan coverage. In most cases, medical insurance plans will cover some major oral surgery procedures. Your medical insurance may also cover the cost in full or in part for medically-related oral surgery procedures, depending on your plan, medical health status, and the type and degree of difficulty of the surgery.
| Characteristics | Values |
|---|---|
| Dental procedures covered by medical insurance | Oral surgeries such as removal of diseased teeth, dental implants, biopsies, tumour removals, repair of trauma, and other surgical issues involving the bones and soft tissues of the face |
| Dental procedures covered by Medicare | Dental or oral exams as part of a comprehensive workup prior to certain treatments, dental ridge reconstruction done as a result of tumour removal surgery, services to stabilise or immobilise teeth related to reducing a jaw fracture, dental splints used for covered treatments, medically necessary diagnostic and treatment services to eliminate oral or dental infections prior to or during dialysis services for ESRD, dental services linked to the success of medical treatments like oral exams and dental treatments before heart valve replacement or transplants |
| Dental procedures not covered by Medicare | Routine dental care, services for the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth, alveoplasty, dentures, implants |
| Dental procedures not covered by medical insurance | Routine dental treatments and preventative care |
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What You'll Learn
Oral surgery
Dental insurance typically covers oral surgery, especially if it is a standard dental procedure such as wisdom tooth extraction. Basic dental insurance procedures include fillings, extractions, crowns, bridges, and oral surgeries. However, dental insurance is primarily designed for preventive and routine care, and out-of-network costs can be significantly higher.
Medical insurance usually covers oral surgery if it is deemed medically necessary, resulting from accidents, injuries, or a medical condition affecting the mouth, such as oral cancer. Medical insurance typically covers oral surgery as the primary payer with no yearly maximum, while dental coverage coordinates benefits as the secondary payer. Oral surgeries covered by medical insurance may include:
- Jaw surgery to correct sleep apnea or TMJ disorders
- Wisdom tooth extraction in some cases
- Repair of cleft palate and other congenital abnormalities
- Removal of teeth before radiation therapy of the head and neck
- Excision of cysts or tumours in the jaws or facial bones
- Reconstruction following cancer surgery
- Reduction of facial bone fractures
- Removal of broken teeth necessary for reducing a jaw fracture
- Dental services following non-biting accidents
- General anaesthesia when local anaesthesia is insufficient
It is important to note that medical insurance typically does not cover cosmetic procedures or orthodontic braces to correct TMJ. Additionally, dental implants may be covered by medical insurance if they arise from medical conditions or accidents but not for cosmetic reasons.
To determine coverage, it is recommended to consult with your dentist or insurance provider beforehand to understand how much of the procedure will be covered and how to bill for it.
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Dental insurance plans
Oral Surgery
Medically Necessary Procedures
Dental Anaesthesia and Sedation
Anaesthesia administered by a registered anesthesiologist is often covered by health insurance. In contrast, dental insurance typically covers nitrous oxide or oral sedation used during dental procedures.
Preventative Treatments
Dental Emergencies
Dental insurance can provide coverage for dental emergencies, such as treating a complication arising from head and neck cancer treatment or addressing dental splints for a dislocated jaw joint.
It is important to note that each dental insurance plan is unique, and the coverage provided can vary. Always communicate with your insurer before undergoing a dental procedure to understand what is covered under your specific plan. Additionally, coordination between your dental insurance provider and medical insurance provider may be required to ensure proper billing and reimbursement.
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Medical insurance plans
Medicare, for example, generally does not cover routine dental care such as cleanings, fillings, tooth extractions, dentures, or implants. However, it may cover dental services that are integral to or linked to the clinical success of other Medicare-covered procedures. This includes dental exams and treatments to eliminate oral or dental infections before or during medically necessary treatments such as organ transplants, chemotherapy, dialysis, or surgery for head and neck cancer. Medicare Part A and Part B may also cover ancillary services and supplies related to covered dental services.
For dental surgeries, both your dental and medical insurance plans may contribute to the cost, depending on the procedure and your insurance coverage. Oral surgeries, such as the removal of diseased or impacted teeth, dental implants, biopsies, tumour removals, and trauma repair, can be covered by medical insurance if they are considered medically related. The level of coverage will depend on the specific surgery, your medical health status, and the type and complexity of the procedure.
It is recommended to speak with your dentist or dental specialist and your insurance provider to determine if your procedure is covered and to understand the billing process. Dental providers can advise on their experience with filing medical claims, while insurance providers can provide estimates of coverage and expected out-of-pocket costs.
Additionally, it is worth noting that health insurance plans typically cover medically necessary treatments, while dental plans cover preventative treatments. Anesthesia administered by a registered anesthesiologist is often covered by health insurance, while sedation is usually covered by dental insurance. Implants may be covered by health insurance if they are related to oral cancers or bone loss.
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Medicare coverage
Medicare typically does not cover routine dental care, including cleanings, fillings, tooth extractions, and dentures or implants. However, there are some exceptions where Medicare may provide limited coverage for specific dental procedures or services. Firstly, Medicare Advantage Plans (Part C) offered by private insurance companies may include dental coverage, but not all plans do, and the extent of coverage varies. These plans often have deductibles, copays, and coinsurance, and it is important to review the details before enrolling.
Secondly, in certain instances, Original Medicare (Part A and Part B) may cover dental services that are deemed medically necessary and are linked to the success of other covered medical treatments. For example, Medicare may cover oral exams and dental treatment before heart valve replacement, organ transplants, or cancer treatments like chemotherapy. It may also cover procedures to treat oral infections before dialysis services for patients with ESRD. Additionally, Medicare may cover dental services related to the treatment of jaw-related diseases, such as oral cancer, or in cases of traumatic injuries affecting the jaw, teeth, or mouth.
Medicare payment policies for dental services have undergone some changes in recent years, with the 2023, 2024, and 2025 rules defining new clinical scenarios for which Medicare payment can be made. However, these changes are expected to benefit only a small number of Medicare beneficiaries and do not represent a broad expansion of dental coverage.
It is worth noting that Medicare Supplement Insurance plans and Medicare Physician Fee Schedule Final Rules do not offer coverage for dental services. While Medicare coverage for dental procedures is limited, some beneficiaries may have access to dental coverage through other sources, such as Medicare Advantage Plans or standalone dental insurance plans.
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Dental emergencies
Most dental insurance plans cover emergency dental care, but the extent of coverage varies depending on the specific plan and provider. Some plans may cover emergency treatments fully, while others may only cover a portion of the costs. It is important to review your policy to understand the coverage limits and any applicable deductibles or co-pays. The type of dental emergency and the required treatment can also impact coverage, with some plans covering certain emergency treatments more comprehensively than others.
In general, dental insurance plans follow the 100-80-50 model, where preventive care, including cleanings and checkups, is 100% covered, basic treatments such as fillings are covered at 70-80%major procedures like crowns and root canals are covered at 40-50%. Many dental insurance plans also cover one emergency exam per year, which can help reduce total treatment costs.
If you experience a dental emergency, it is crucial to seek professional care as soon as possible. Contact your dentist immediately during regular office hours, as many dental practices have emergency slots for urgent cases. If the emergency occurs outside of regular hours, check if your dentist has an after-hours emergency number or on-call service. If not, visit an urgent care clinic or emergency room if the situation is severe. It is recommended to call your dentist first, as they are equipped to address specific dental issues, while ER doctors may not. Additionally, the ER may not accept your dental insurance benefits, whereas your dentist will.
It is also important to consider whether you have met your deductible for the year and how much coverage you have left on your annual maximum. If your dental emergency is related to a pre-existing condition, coverage may be limited, so check your policy for any exclusions. Finally, if your emergency is the result of an accident or trauma, it may be covered under your medical insurance plan instead of dental insurance.
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Frequently asked questions
This depends on your insurance provider and plan coverage. It is recommended that you consult your insurance plan before booking any dental procedures to see what is and isn't covered. Typically, anything medically necessary is covered by health insurance, while dental plans cover preventative treatments.
Dental insurance covers the cost of preventative treatments and check-ups.
In most cases, medical insurance plans will cover some major oral surgery procedures. However, this depends on your insurance provider and plan coverage.
Yes, dental insurance usually covers common oral surgeries, at least in part. However, this depends on the specific type of surgery, your dental plan, and your level of coverage.
Medically necessary is anything that directly affects your quality of life and well-being.
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