Navigating the Maze: Does Your Insurance Cover These 5 High-Cost Dental Procedures?

by Dr. Richard J. Walicki | Feb 3, 2024 | Dental Insurance

A trip to the dentist can be a breeze… until the bill arrives. High-cost procedures like root canals, crowns, and implants can wreak havoc on your budget, especially if you’re unsure about your insurance coverage.  In this blog post, we want to help you navigate through the maze. This guide will illuminate the murky waters of dental insurance, focusing on five common high-cost procedures:

Root Canals: Root canals may be the source of many dental jokes and cause some dental anxieties, but sometimes they are necessary to save a tooth. While insurance often covers some portion, expect out-of-pocket costs.

• Some insurance companies classify root canals as a “major” procedure. This typically results in lower coverage percentages, often 50% of the allowed amount set by the insurance company.
• Other insurance companies might categorize root canals as a “basic” procedure. This could lead to higher coverage percentages, potentially reaching 70% to 80%.

Therefore, it’s crucial to:

• Consult your specific insurance plan documents to understand how they categorize root canals. This will directly impact the coverage percentage you can expect.
• Remember that the “allowed amount” might differ from the dentist’s actual charge. So, even with high coverage, you might still have out-of-pocket costs.

Remember – coverage levels vary, potentially ranging from 50% to 80% of the “allowed amount” set by your insurance company, which is not necessarily the full dentist’s charge. Remember, deductibles and co-pays apply!

Crowns: Cracked, chipped, or weakened teeth often find solace in crowns. Again, insurance might offer partial coverage, but it’s important to understand the specifics. Material plays a role; porcelain crowns usually enjoy higher coverage than metal ones. Be prepared for out-of-pocket expenses based on your plan’s coverage percentage and chosen material.  Here’s a little bit more about where costs can add up, though.

Buildups and Insurance Coverage:

• Crowns often fall under the “major” category in insurance plans. This means they typically have lower coverage percentages, ranging from 50% to 80% of the “allowed amount” set by the insurance company.
• Buildups are additional procedures often needed before placing a crown. They add structural support to weakened teeth, ensuring the crown’s stability and longevity.
• The issue: Many insurance companies are increasingly denying coverage for buildups, claiming they are considered “cosmetic” or “preventive” procedures, even though they are often crucial for the success of the crown itself.

Reasons for Denial:

• Cost-cutting measures: Insurance companies might view buildups as an unnecessary expense and deny coverage to save money.
• Lack of standardized guidelines: Clear definitions and criteria for buildup coverage are often absent in insurance policies, leading to inconsistencies and denials.
• Misinterpretation of medical necessity: Some companies might not recognize the functional purpose of buildups and categorize them incorrectly.

Impact on Patients:

• Increased out-of-pocket costs: Denied coverage for buildups can leave patients with significant financial burdens, potentially hindering their ability to receive necessary dental care.
• Confusion and frustration: The lack of transparency and inconsistent application of coverage policies can cause confusion and frustration for patients navigating the insurance system.

What Patients Can Do:

• Appeal the denial: If your insurance denies coverage for a buildup, you have the right to appeal the decision. Gather documentation from your dentist supporting the medical necessity of the procedure and submit it to your insurance company.
• Advocate for change: Contact your insurance company and state officials to express your concerns about the growing issue of denied coverage for buildups.

Implants: Replacing missing teeth with implants provides a natural-looking, long-lasting solution. Unfortunately, even though modern implants have been around for more than fifty years, they are still considered elective or even cosmetic by insurance companies, resulting in minimal to no coverage. Be prepared to shoulder the majority of the cost yourself.

Insurance Coverage for Dental Implants:

• Implants primarily serve a functional purpose. They replace missing tooth roots, restoring chewing function, speech, and preventing bone loss in the jaw. From that perspective, implants could be considered medically necessary.
• However, insurance companies often focus on the visible part of the implant, which is the crown placed on top. This crown, similar to a traditional crown, restores the aesthetics of the smile. Because restoring aesthetics falls under the umbrella of cosmetic dentistry, some insurance companies label the entire implant procedure as cosmetic and exclude it from coverage.
• Additionally, the high cost of implant procedures plays a role in coverage decisions. Insurance companies might prioritize covering more “essential” procedures within their budget limitations.

Important Caveats:

• Coverage for implants varies significantly between insurance plans. Some plans might offer partial coverage, especially if deemed medically necessary due to specific criteria like bone loss or impact on surrounding teeth.
• Individual circumstances significantly influence coverage. The procedure’s purpose, medical necessity, and alternative treatment options can all affect how an insurance company views an implant case.
• Consulting your dentist and insurance provider is crucial. They can explain your specific plan’s coverage details and help navigate the intricacies of claiming for an implant procedure.

Remember:

• Even if your insurance doesn’t cover the full cost of implants, alternative financing options like CareCredit or dental loans can ease the financial burden.
• Prioritizing preventive care and regular checkups can help prevent tooth loss and the need for implants in the first place.

Oral Surgery: Wisdom teeth causing trouble? Oral surgery might be the answer. Coverage here depends on the specific procedure and its medical necessity. Simple wisdom tooth extractions might be partially covered, while complex jaw surgery might have limited or no coverage. Consult your dentist and insurance provider for clarification.

Coverage for complex jaw surgery, even if performed by an oral and maxillofacial surgeon, can be quite complex and nuanced. It depends on several factors, including:

1. The specific diagnosis and reason for surgery:

• If the surgery is deemed medically necessary to address a functional issue like sleep apnea, severe malocclusion impacting chewing, or facial trauma, there’s a higher chance of coverage under medical insurance.
• If the surgery is primarily for cosmetic reasons, it’s highly unlikely to be covered by medical insurance.

2. The specific procedure and its complexity:

• Simple jaw surgery procedures like wisdom tooth extraction might be covered partially or fully under medical insurance, depending on the diagnosis and complexity.
• Complex jaw surgery like orthognathic surgery for severe malocclusion typically falls under medical insurance, but coverage varies depending on the plan and specific details of the case.

3. Your specific medical insurance plan:

• Each plan has its own criteria for covering medically necessary procedures. Carefully review your plan’s specific coverage details, including exclusions and pre-authorization requirements.

4. The provider’s network participation:

• If the oral and maxillofacial surgeon is within your medical insurance network, there’s a higher chance of coverage and potentially lower out-of-pocket costs. Out-of-network providers might require higher patient responsibility.

Here are some resources that can help you understand your coverage:

• Your medical insurance provider: Contact their customer service or review your plan documents online.
• The oral and maxillofacial surgeon’s office: They can help you navigate the pre-authorization process and understand estimated costs based on your insurance plan.
• The American Association of Oral and Maxillofacial Surgeons (AAOMS): Their website has resources on insurance coverage and finding an in-network provider: https://www.aaoms.org/

Remember:

• Even with medical insurance coverage, there might be out-of-pocket costs like deductibles, coinsurance, and copays. Discuss these costs with your doctor and insurance provider beforehand.
• Getting pre-authorization from your insurance company before the procedure is crucial to maximize coverage and avoid unexpected denials.

It’s crucial to consult with your specific medical insurance provider and the oral and maxillofacial surgeon to understand your individual coverage situation for complex jaw surgery. Don’t hesitate to ask questions and advocate for yourself to ensure you receive the necessary care with the best possible financial outcome.

Dentures: Replacing a full set of teeth with dentures can significantly impact your quality of life, so you need to know that insurance coverage for dentures varies.

• Both full and partial dentures can have some coverage under dental insurance plans, but the extent of coverage varies considerably.
• Factors influencing coverage:
  • Type of denture: Full dentures typically receive higher coverage than partial dentures because they replace an entire set of teeth and are considered more medically necessary.
  • Material used: Acrylic dentures usually have higher coverage than implant-supported dentures, which might be viewed as more cosmetic due to the implant component.
  • Plan limitations: Deductibles, co-pays, annual maximums, and specific exclusions listed in your plan all play a role in determining the final coverage amount.
• General coverage range: While exact percentages depend on your plan, full dentures often enjoy coverage between 30% and 80%, while partial dentures might fall between 20% and 50%. However, coverage could be zero for both, depending on the factors mentioned above.

When it comes to any dental procedure, remember:

• Always consult your insurance provider and dentist to understand your specific plan’s coverage details for both full and partial dentures.
• Coverage details often differ between companies and even between different plans within the same company.
• Alternative financing options can help manage the costs not covered by insurance.

• “Allowed amount” is not the same as the dentist’s charge. Understand your plan’s limitations and potential out-of-pocket costs.
• Plan exclusions exist. Cosmetic procedures rarely receive coverage.
• Don’t delay treatment due to cost concerns. Discuss options with your dentist and explore financing options if needed.

Bonus Tip: Consider a Flexible Spending Account (FSA) or Health Savings Account (HSA) to set aside pre-tax dollars for dental expenses.

Navigating dental insurance can feel like climbing Mount Everest, but with knowledge and careful planning, you can scale the financial peaks and achieve a healthy, confident smile. So, gather your maps, ask questions, and don’t be afraid to seek professional guidance. Remember, a proactive approach is key to conquering the cost conundrum!