Is Jaw Surgery Covered by Insurance?

Jaw surgery, also known as orthognathic surgery, is a procedure that helps fix problems with the jaw and teeth. Many people consider this surgery to improve their bite, speech, or overall appearance. However, one big question often arises: Is jaw surgery covered by insurance?

Understanding whether your insurance will help pay for jaw surgery is really important. Medical bills can be high, and knowing your options can save you a lot of money and stress. In this article, we will explore how insurance coverage works for jaw surgery, what factors can affect it, and what steps you can take to ensure you get the help you need.

Types of Jaw Surgery

Jaw surgery, also known as orthognathic surgery, is performed to correct misaligned jaws. Here are the main types:

1. Maxillary Osteotomy: This surgery corrects the position of the upper jaw (maxilla). It’s used to treat conditions like an excessive overbite, crossbite, or open bite.
2. Mandibular Osteotomy: This surgery adjusts the position of the lower jaw (mandible). It’s often performed when the lower jaw protrudes or recedes significantly.
3. Bimaxillary Osteotomy: This involves surgery on both the upper and lower jaws. It’s recommended when conditions affect both jaws.
4. Genioplasty: This surgery is performed to reposition the chin, either advancing or reducing it.
5. TMJ Surgery: This targets the temporomandibular joint (TMJ) to relieve pain and improve function in cases of TMJ disorders.

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Each type of jaw surgery addresses specific problems and improves functions like chewing, speaking, and breathing, along with enhancing facial aesthetics.

When Is Jaw Surgery Considered Medically Necessary?

Jaw surgery is considered medically necessary when it is required to address functional issues or health conditions that significantly affect a person’s quality of life or physical well-being. Insurance companies often use this classification to determine whether they will cover the procedure. Below are the common criteria for medical necessity:

1. Severe Malocclusion: When teeth do not align properly, causing difficulty in chewing, biting, or speaking.
2. Obstructive Sleep Apnea: When the airway is blocked during sleep, leading to breathing difficulties.
3. Temporomandibular Joint Disorders (TMJ): Chronic jaw joint pain or dysfunction that affects jaw movement.
4. Facial Trauma: Injuries that result in misalignment or functional issues of the jaw.
5. Congenital Disabilities: Conditions present from birth, such as cleft palate, that affect jaw structure and function.
6. Chronic Mouth Breathing and Dry Mouth: Conditions that can lead to other health issues if not corrected.

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In each case, the surgery must be expected to improve the functional impairment. Insurance companies typically require thorough documentation and evidence of the condition’s impact on daily life.

Does Health Insurance Cover Jaw Surgery?

Health insurance may cover jaw surgery, but whether it is covered largely depends on the purpose of the procedure and the specific terms of your policy. Generally, health insurance is more likely to cover jaw surgery if it is deemed medically necessary.

This typically includes surgeries to correct functional issues such as difficulty chewing, swallowing, or breathing; treating conditions like sleep apnea or temporomandibular joint (TMJ) disorders; or addressing severe facial trauma or congenital abnormalities.

To qualify for coverage, insurers often require extensive documentation from your healthcare provider, including proof of medical necessity and a detailed treatment plan. Preauthorization is usually required to ensure the procedure meets the insurer’s criteria. Cosmetic jaw surgeries, however, are rarely covered, as they are considered elective procedures.

Does Dental Insurance Cover Jaw Surgery?

Dental insurance may cover jaw surgery, but it largely depends on the purpose of the procedure and the specific terms of your policy.

Typically, dental insurance is more likely to cover surgeries directly related to oral health, such as correcting bite issues, removing impacted wisdom teeth, or addressing severe malocclusion.

However, when jaw surgery involves broader health concerns, like correcting facial deformities or treating temporomandibular joint (TMJ) disorders, health insurance often becomes the primary coverage, with dental insurance acting as a secondary payer.

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It’s essential to understand the overlap between dental and health insurance, as many policies exclude surgeries deemed cosmetic or non-essential.

Cost of Jaw Surgery

The cost of jaw surgery in the USA can vary widely depending on several factors, including the complexity of the procedure, the surgeon’s fees, hospital fees, anesthesia, and post-operative care. Here’s a general overview:

• Minor Single Jaw Surgery (e.g., Genioplasty): Costs range from $5,000 to $15,000.
• Intermediate Procedures (e.g., Mandibular Osteotomy): Costs range from $15,000 to $35,000.
• Major Dual Jaw Surgery (e.g., LeFort I and BSSO): Costs range from $40,000 to $60,000.
• Complex Bimaxillary Surgery with Bone Grafting and Genioplasty: Costs can exceed $50,000.

These prices can be significantly offset by insurance coverage if the surgery is deemed medically necessary.

Factors Affecting Insurance Coverage

Several factors can influence whether your insurance will cover jaw surgery:

1. Type of Insurance: Health insurance may offer broader coverage compared to dental insurance. Medical insurance is more likely to cover surgeries addressing functional issues, while dental insurance may cover procedures involving teeth or gums.
2. Medical Necessity: Insurance companies typically cover surgeries deemed medically necessary, such as correcting severe malocclusion or treating obstructive sleep apnea. Cosmetic surgeries are usually not covered.
3. Provider Network: In-network providers often offer better coverage rates than out-of-network providers. It’s important to check if your surgeon is in-network.
4. Policy Limitations: Some insurance plans have exclusions or caps on certain procedures. Review your policy details to understand any limitations.
5. Pre-Authorization Requirements: Many insurers require pre-approval before covering surgery. This involves submitting documentation from your healthcare provider to justify the medical necessity of the procedure.
6. Location of Service: Coverage may vary by state and the facility where the surgery is performed. It’s essential to verify coverage based on the location.
7. Pre-Existing Conditions: Some insurance plans may have specific rules regarding pre-existing conditions, which can affect coverage.

Understanding these factors can help you navigate the complexities of your insurance policy and better prepare for any out-of-pocket expenses.

What to Do If Insurance Denies Coverage?

If your insurance denies coverage for jaw surgery, don’t be discouraged; there are steps you can take to appeal the decision. Start by thoroughly reviewing the denial letter to understand the specific reasons for the denial.

Gather all necessary medical documentation from your healthcare providers, including detailed reports, X-rays, and a letter of medical necessity that explains why the surgery is crucial for your health.

Submit a formal appeal to your insurance company, addressing each reason for denial and providing additional evidence to support your case. It may also be beneficial to involve your oral surgeon or orthodontist in this process, as they can provide expert testimony.

If the initial appeal is unsuccessful, consider seeking assistance from a patient advocate or exploring the possibility of a second-level appeal. Persistent and well-documented appeals can significantly increase your chances of getting the insurance coverage you need.

Alternatives to Insurance Coverage

When insurance does not cover jaw surgery, there are several alternatives to help manage the costs. One option is to set up a payment plan with your surgeon or hospital, allowing you to pay the surgical fees in installments.

You can also look into medical loans specifically designed for healthcare expenses, which often offer lower interest rates. Additionally, healthcare credit cards like CareCredit can provide financing options. Some hospitals and clinics offer financial assistance programs or sliding scale fees based on income.

Lastly, it’s worth checking if any charitable organizations or foundations provide grants or funding for medical procedures. Exploring these alternatives can help make the costs more manageable.

FAQs

Conclusion

Jaw surgery can be a crucial treatment for many people with serious jaw issues. Understanding if insurance will cover the cost is important. Insurance might cover the surgery if it’s needed for health reasons, but often doesn’t if it’s for looks only.

There are several types of jaw surgery, each targeting different issues. The cost of jaw surgery can be high, especially in the USA, but there are ways to manage these costs, like payment plans, medical loans, and financial aid programs.

If your insurance denies coverage, appealing the decision with proper documentation can help. Exploring alternative financing options can make the surgery more affordable for those not covered by insurance.

Archer Finnegan

Archer Finnegan is a certified health insurance advisor with over 7 years of experience in the industry. Holding a CHIA (Certified Health Insurance Advisor) designation, Archer is passionate about helping people understand their coverage options. As an author on our Insurance Guy blog, Archer writes easy-to-understand articles that make health insurance simple and accessible for everyone.