The Delicate Dance of Dental Insurance and Oral Surgery Explained

woman considering dental work

So, we all know that dental insurance covers our bi-yearly dental cleanings and exams; a general rule of thumb with all types of health insurance is that preventative care is almost always covered completely, maybe minus a copay or two. Many plans include yearly oral x-rays in this coverage. But after cleanings and exams, things get a little sticky, especially regarding oral surgery.

Two really common FAQs from our patients are (1) Will my oral surgery be covered?, and (2) Is my oral surgery covered under dental insurance or medical insurance? At the end of the day, the answer to these questions depend on your dental plan, which is why it’s so important to consult with an oral surgeon who makes it a point to work with insurance companies to make the most out of your coverage. And regardless of plan specifics, there are some general metrics most dental insurance providers follow.

What’s Typically Covered under Dental Insurance?

Many plans cover dental care under the 100-80-50 model. That means they completely cover preventative care (100%), cover most of minor procedures (80%), and cover half of more complicated/involved procedures (50%). Oral care, procedures and surgeries covered include:

  • 2x year checkups
  • 1x year x-rays
  • Cavity removal and filling/crowns
  • Root canals
  • Wisdom tooth removals
  • Tooth replacements like dentures, bridges or crowns
  • Emergency oral surgeries due to facial trauma/accidents

Some of these procedures are covered more than others, but the gist of most dental insurance plans is that the more necessary something is to preserving your oral health, the more likely they are to cover most to all of it. Why? It’s not like they’re worried about your out-of-pocket costs and plan payments. They cover necessary procedures because it saves them money in the long run.

Think about it: if they pay for the common dental practices and minor oral surgeries, you’re less likely to:

  • Run past your deductible: After you surpass your deductible, the insurance company pays for everything, up to whatever limit you chose for your plan.
  • Need more extensive oral health issues fixed in the long run: This means after your deductible, each year you’re more likely to spend at or past the cap limit on your dental plan.

This is also low-key why the government put fluoride in the public water supply: prevention is almost always the cheaper way for providers of health insurance to go. It’s a combination of risk-reward and better-safe-than-sorry.

Other oral surgeries and treatments, dental insurance views as purely cosmetic, so they won’t cover them. This is especially true for procedures like teeth whitening. As well, in cases where a patient needs dental implants, often there has to be an involved discussion between your dentist, oral surgeon and insurance provider about why dental implant surgery isn’t just cosmetic in order to get some coverage for it.

Providers also don’t take kindly to covering oral health issues resulting from a pre-existing medical condition (think Diabetes II, or damage from cancers resulting from smoking). In all, dental insurance coverage expects mutual investment: they’ll invest in paying for keeping your mouth healthy, but they also expect you to in turn care for your mouth properly as well.

When is Oral Surgery run Through Medical Insurance Instead?

Some kinds of oral surgery are viewed as general health issues even though they primarily involve the mouth. That’s why it’s important to have both medical and dental coverage: so all your bases are covered. And, as an aside, not all dental plans have orthodontia treatment coverage; so if you’ve got a kid who’s going to need braces, make sure you get a dental plan with orthodontia coverage.

Anyway, it depends on your insurance plans as to whether an oral surgery will be covered by medical or dental. Oral and maxillofacial surgery is by nature interdisciplinary, after all. Factors that affect which plan covers what include:

  • Reason: If the procedure you’re looking at is necessary for not just the health of your mouth, but your overall well-being, it will fall under your medical plan. Another way to get around dental insurance plans not providing coverage for procedures resulting from a medical condition, some medical insurance plans will give you the right to dental coverage because of a pre-existing condition. Why? Again, it saves the insurance provider money in the long run by helping you maintain your health; the medical insurance provider is looking at their bottom line.
  • Sedation: If a procedure just requires oral sedation, it will be billed under your dental plan, whereas if the oral or maxillofacial procedure requires IV sedation by a licensed anesthesiologist will probably fall under your medical plan.
  • Setting: If the oral surgery is complicated, such as full mouth reconstructions from facial trauma or pediatric maxillofacial surgery, it will occur in a hospital and not at the oral surgeon’s office. These procedures usually fall under medical, not dental.

Making the Most out of Your Dental Insurance

Just like pretty much every kind of health insurance coverage, what’s covered when and where is almost never transparent. That’s why the best way to take full advantage of your dental insurance and/or your medical insurance when you need an oral surgical procedure is to talk to your oral surgeon. They’ll be able to tailor your treatment plan in a way that optimizes the results of the procedure as well as the amount of coverage by your insurer.