Tooth Extraction: Insurance Coverage?

Tooth extraction is considered a medical procedure by most insurance companies and is often covered by dental insurance if it is deemed medically necessary by a dentist or oral surgeon. The amount covered depends on the type of procedure and the patient's insurance plan. Some insurance plans may also require a waiting period before covering tooth extractions.

Dental insurance plans

There are several types of dental insurance plans:

• Preferred provider organization (PPO): These plans come with a list of dentists and other oral health care providers that accept the plan, known as in-network providers. Going to an in-network provider will give you the lowest out-of-pocket cost. You may be able to go out of network, but your out-of-pocket costs will be higher.
• Dental health maintenance organization (DHMO): DHMO plans provide a network of dentists that accept the plan for a set co-pay or no fee at all. However, you may not be able to see an out-of-network dentist, and if you do, you may have to pay the full amount yourself.
• Discount or referral dental plan: This type of plan offers you a discount on dental services from a select group of dentists. Unlike health insurance, this type of plan doesn't pay anything for your care; instead, the dentists who participate agree to give you a discount. These plans are also called access or savings plans.
• Private dental insurance: Private dental insurance is purchased directly from a dental insurer, HealthCare.gov, or an insurance broker, rather than through an employer.

When it comes to tooth extractions, dental insurance generally covers them if they are medically necessary. However, the amount covered will depend on the type of procedure and your specific plan details. Some plans may cover 50% of the cost, while others may cover 80% for basic care. If your dental plan pays 80% for basic care, you would only pay the remaining 20%.

It's important to note that dental insurance plans may have waiting periods before you can use your benefits for certain procedures, such as non-surgical extractions. However, it is possible to find plans without waiting periods. Group dental insurance plans purchased through your employer may offer this option.

Additionally, if you have health insurance, it may cover a portion of a tooth extraction procedure, further reducing the amount you have to pay. It's a good idea to contact your insurer to see if oral surgery is covered under your plan.

Medical insurance plans

Tooth extractions are often considered a dental procedure, but they can also be classified as a medical procedure if they are used to diagnose or treat a medical condition. For example, if a patient has an abscessed tooth, this would be considered a medical condition, and the extraction would likely be covered by medical insurance.

It is important to note that medical insurance plans typically cover major oral surgery procedures, but the specific type of surgery, the patient's medical health status, and the degree of difficulty of the surgery will also determine whether the procedure is covered.

Additionally, some insurance plans may require that the dental insurance company be billed first, and then once that claim is processed, a claim can be filed towards medical insurance.

It is always recommended to consult with the dentist or oral surgeon's office staff to see if they have experience filing medical claims and to get an idea of the likelihood of receiving coverage. It is also advisable to contact the medical insurance provider directly to understand what the plan covers and what out-of-pocket costs to expect.

Oral surgery

Dental Insurance

Dental insurance usually covers routine cleanings at 100%. However, policies have a low annual maximum benefit and only pay a small fraction of the cost of other treatments. Dental insurance also tends to have a low annual maximum benefit, so patients with complex issues can quickly exhaust their dental benefits for the year.

Dental insurance generally covers extractions if they are medically necessary. However, tooth extractions can be pricey if you don't have insurance. The exact cost of a tooth removal procedure depends on a few factors, including the type of extraction required and the number of teeth that need to be pulled.

Dental insurance plans that cover basic procedures, including extractions, pay at different percentages based on the individual plan. You may have a policy that may pay 50% or you could find a plan that pays 80% for basic care. If your dental plan pays 80% for basic care, you would pay the remaining 20%.

Medical Insurance

When it comes to oral surgery, your medical insurance may cover all or a portion of the healthcare bill, depending on your provider and plan coverage. Most common oral surgeries are covered, at least in part, by your dental insurance provider. However, this depends on the specific type of surgery you need, your dental plan, and your level of coverage.

Your medical insurance may also pick up the cost in full or part for medically-related oral surgery procedures depending on your plan, medical health status, and the type and degree of difficulty of the surgery. Costs may be covered for the diagnosis, treatment, or prevention of a medically-related oral condition or for the rehabilitation of lost skills related to the problem.

Examples of Oral Surgery Procedures

• Surgical treatments: Difficult wisdom tooth extractions and other complex tooth removals, soft and hard tissue biopsies, frenectomies on newborns, correction of facial deformities, cancer-related treatment, and dental implants.
• Dental/facial trauma: Injuries resulting from automobile or other accidents, teeth that have been knocked loose or knocked out.
• Diagnostic procedures: Certain X-rays (non-routine ones), bacterial testing, and testing used to discover the source of oral and myofascial pain.
• Non-surgical medical procedures: Emergency treatments for inflammation and infection, drainage of abscesses, general anesthesia for surgeries, and appliances for TMJ or sleep apnea.

Simple extractions

A simple extraction is a type of tooth extraction procedure. It is performed when the tooth is easily accessible and visible in the mouth. This procedure is commonly done using two instruments: an elevator and dental forceps. The elevator loosens the tooth, and the forceps grasp the tooth for its extraction.

Dental insurance generally covers extractions if they are medically necessary. However, the exact cost of a tooth removal procedure depends on a few factors, including the type of extraction required and the number of teeth that need to be pulled.

Most dental insurance plans will only pay for care if you go to a contracted and participating in-network dentist, orthodontist, or other oral health care specialist. Going to an in-network provider often results in the lowest out-of-pocket costs for you.

Some dental insurance plans may have a waiting period before you can use your benefits for certain procedures. For example, you might have to wait six months before your plan will cover non-surgical extractions.

It is recommended that you have a conversation with your dentist or dental specialist office staff to see if they have experience filing medical claims. They should be able to give you an idea of the likelihood of receiving coverage and help you obtain a predetermination of benefits.

You can also talk directly with your medical insurance provider to see if your procedure is covered, get an estimate of how much they will pay, and gain a better sense of what out-of-pocket costs to expect.

Surgical extractions

The cost of a surgical extraction is typically higher than that of a simple extraction, ranging from $250 to $370 on average. However, the price can vary depending on factors such as the complexity of the procedure, the patient's location, and the provider performing the surgery.

When it comes to insurance coverage for surgical extractions, it's important to distinguish between dental insurance and medical insurance. Dental insurance typically covers routine dental care and may provide some coverage for simple or routine extractions. On the other hand, medical insurance considers oral health as an integral part of overall health and may cover oral surgery procedures, especially if they are medically necessary.

In the context of medical insurance, a surgical tooth extraction may be covered if it is deemed medically necessary. This could include situations where the extraction is required to treat a diagnosed medical condition, such as an abscessed tooth, diabetes, or traumatic injuries affecting the mouth. Medical insurance may also cover oral surgery procedures related to cancer treatment, facial deformities, or dental/facial trauma resulting from accidents.

It is recommended to consult with the dentist or oral surgeon's office staff to determine their experience with filing medical claims. They can provide an estimate of the likelihood of receiving coverage and assist in obtaining a predetermination of benefits. Additionally, individuals should communicate directly with their medical and dental insurance providers to understand their specific plans and coverage levels for oral surgery procedures.

Frequently asked questions