Does Medi-Cal Cover Wisdom Teeth Removal?

Medi-Cal, California’s Medicaid program, provides health coverage for eligible low-income individuals and families. A common question concerns its coverage for wisdom teeth removal, a procedure many individuals require. While Medi-Cal dental services generally focus on essential treatments, wisdom teeth removal can be covered. This article clarifies when and how such procedures are included under Medi-Cal’s dental benefits.

Understanding Medi-Cal Dental

The dental component of Medi-Cal is known as the Medi-Cal Dental Program, or Denti-Cal. This program provides essential dental services to eligible Californians, ensuring access to necessary oral healthcare. Full-scope Medi-Cal beneficiaries are automatically enrolled in Denti-Cal and do not need to apply separately for dental benefits. Denti-Cal covers diagnostic, preventive, restorative, and emergency treatments for both children and adults.

Wisdom Teeth Removal Coverage Under Medi-Cal

Denti-Cal covers wisdom teeth removal, but coverage is contingent upon demonstrating medical necessity. This means the extraction must address a specific dental problem, rather than being performed for purely preventative or cosmetic reasons. For instance, coverage is provided for impacted wisdom teeth causing pain, infection, significant damage to adjacent teeth, or the presence of cysts or tumors.

Surgical extractions of impacted wisdom teeth, as well as simpler extractions, are covered when medically indicated. The dental provider must document the specific issues making the removal necessary, such as chronic pain, recurring infections, or orthodontic concerns directly linked to the wisdom teeth. This documentation ensures the procedure aligns with Denti-Cal’s criteria for medically necessary dental treatment.

Accessing Care and Authorization

To begin the process of wisdom teeth removal under Medi-Cal, individuals must first locate a Denti-Cal provider. The Medi-Cal Dental provider website, Smile, California, offers a search tool to find participating dentists and oral surgeons. Alternatively, assistance can be obtained by calling the Medi-Cal Dental Customer Service Center Line at 1-800-322-6384.

For complex cases, such as the removal of impacted wisdom teeth, a referral from a general dentist to an oral surgeon is often a necessary first step. Most complex wisdom teeth removals require prior authorization from Denti-Cal before the procedure can be performed. This involves the dental provider, typically the oral surgeon, submitting a Treatment Authorization Request (TAR) to Denti-Cal. The TAR must include comprehensive documentation, such as X-rays, clinical notes, and a detailed justification for medical necessity. Providers should not proceed with treatment until authorization is received, as prior authorizations are generally not transferable.

Patient Costs and Program Specifics

Many services under Denti-Cal are provided at no or low cost to the beneficiary. For adults, Denti-Cal generally covers up to $1,800 in services per calendar year. This is considered a “soft” cap, meaning that services exceeding this amount can still be covered if deemed medically necessary and receive a Treatment Authorization Request (TAR). Notably, certain services, including extractions and emergency dental care, are often exempt from this annual cap.

It is important for beneficiaries to confirm that their chosen dental provider is enrolled with Denti-Cal to avoid unexpected charges. Denti-Cal providers are prohibited from billing beneficiaries for services covered by the program. If a requested service is denied coverage, beneficiaries retain the right to appeal the decision.