Is My Wisdom Teeth Removal Covered by Medical Insurance?

Wisdom teeth removal is a common dental procedure, but many are unaware of whether their medical insurance will cover it. Generally, the answer is no. As a dental procedure, extractions fall under the jurisdiction of dentists, not medical physicians, and are usually performed in a dental office rather than a hospital. This distinction can have significant implications, as dental procedures can be expensive and not all dental insurances cover all treatments.

In the United States, generally no, tooth extractions are not considered medical procedures. They pertain to the purview of dentists, not physicians, and happen in dental offices rather than hospitals. If dental offices could bill insurance plans directly, it could lead to a significant spike in dental costs due to the deep pockets of medical insurance.

There have been instances where small medical plans were exploited through creative billing techniques. However, due to increased awareness and regulations, such abuses are becoming less common. Big data and improved auditing practices have been immensely helpful in identifying and preventing such practices.

Why Medical Insurance Typically Doesn't Cover Wisdom Teeth Removal

The primary reason medical insurance does not cover wisdom teeth removal is that it is performed by dental professionals and occurs in a dental setting. Dentists are trained to diagnose and treat conditions related to the mouth and teeth, which includes wisdom teeth issues. Medical insurance, on the other hand, is designed to cover treatments related to general health and disease, not specifically dental care.

The American Dental Association (ADA) and the California Dental Practice Act specify that hygienists are not permitted to diagnose diseases or recommend definitive treatments. This further emphasizes that dental care is distinct from medical care and should be covered under dental insurance plans.

Waiting Period and Special Circumstances

Some dental insurance plans may have a 12-month waiting period from the effective date of the policy before they cover certain procedures. This waiting period can make it difficult for individuals to obtain coverage for wisdom teeth removal if they require it immediately.

In some cases, medical insurance may indeed pay for wisdom teeth removal, but there are specific conditions that must be met. Finding a dentist who is experienced in submitting medical claims can be crucial. In states like Ohio, medical insurance may only cover wisdom teeth removal when there is definitive pathology, and the patient also has dental insurance. Even then, coverage is not guaranteed.

Consulting a Professional

For individuals considering wisdom teeth removal, it is essential to consult both a dentist and their insurance provider to understand the coverage options. A thorough examination by a dentist is necessary to determine if there are realistic medical reasons for the procedure. From there, contacting the dental office and your insurance provider to discuss coverage is critical.

A good starting point is to find a reputable oral surgeon and a dental office that specializes in submitting medical claims. These professionals can help assess the necessity of the procedure and navigate the insurance coverage process.

Remember, the cost of wisdom teeth removal can be substantial, and the premiums for dental insurance may not fully cover the procedure. Seeking help soon is important, as ensuring your overall health, including dental health, is crucial.

In conclusion, wisdom teeth removal is not typically covered by medical insurance due to its dental nature. However, by understanding the specific circumstances under which medical insurance may cover the procedure and consulting qualified professionals, individuals can make informed decisions about their care.