What Insurance Covers Orthognathic Surgery?

Orthognathic surgery is a complex procedure addressing irregularities of the jaw bones. It improves alignment of teeth and jaws, enhancing chewing, speaking, and breathing. Coverage is intricate, depending on the health plan and medical justification. Understanding coverage helps individuals navigate the process.

Understanding Medical Versus Dental Coverage

Orthognathic surgery is typically covered by medical insurance, not dental. This is because it addresses functional impairments and skeletal deformities, falling under medical care. Medical policies consider it reconstructive and medically necessary when improving health and function, not solely for aesthetics.

Dental insurance rarely covers the surgery itself, focusing on routine care, preventative treatments, and restorative procedures. While dental insurance may cover related orthodontic work or tooth extractions, it is not the primary source for surgical coverage. Utilizing medical insurance is fundamental for pursuing coverage.

Establishing Medical Necessity for Coverage

Insurers require orthognathic surgery to be medically necessary, distinguishing it from cosmetic enhancements. Criteria include severe functional impairments affecting chewing, speaking, or breathing. Significant temporomandibular joint (TMJ) disorders or obstructive sleep apnea related to jaw structure also qualify.

Severe malocclusion, or bite problems, uncorrectable by orthodontics alone, are grounds for medical necessity. This includes horizontal overjet of 5 mm or more (or negative value), and anteroposterior molar discrepancies of 4 mm or greater. Vertical discrepancies like open bites greater than 2 mm, or deep overbites with soft tissue impingement, are also considered. Documentation of transverse skeletal discrepancies two or more standard deviations from published norms, or asymmetries exceeding 3 mm, also supports a claim.

Thorough documentation from specialists, including orthodontists and oral surgeons, is essential to establish medical necessity. Documentation should detail the diagnosis, its impact on health and daily functions, and why surgery is the most effective or only viable treatment. Evidence should show non-surgical treatments are exhausted or unsuitable for the underlying skeletal abnormality and functional impairment.

Navigating Pre-Authorization and Appeals

Pre-authorization from the insurance provider is typically required for orthognathic surgery coverage. This process obtains insurer approval before the procedure, confirming it meets medical necessity criteria. Requested information includes medical records, diagnostic images, detailed treatment plans, and letters of medical necessity from providers.

Submit documents timely and follow up consistently, as responses can take four to eight weeks. Approval is often surgeon-specific; switching surgeons may require restarting pre-authorization. A valid authorization is usually time-sensitive, often valid for about 90 days, dictating surgery timing.

If pre-authorization is denied, individuals have the right to appeal. Review the denial letter carefully to understand rejection reasons and the appeals process. Gathering additional supporting documentation, like clinical notes, new diagnostic results, or further letters of medical necessity, strengthens an appeal. Internal appeals allow the insurer to re-evaluate; if still denied, an external review by an independent third party may be possible.

Understanding Costs and Coverage Gaps

Even with insurance approval, orthognathic surgery typically involves out-of-pocket costs. These include deductibles (paid before coverage begins) and co-insurance (a percentage shared with the insurer after the deductible). Patients also have an out-of-pocket maximum, the most they will pay for covered services in a plan year. Without insurance, total costs can range from $20,000 to $40,000, including surgeon’s fees, facility charges, and follow-up care.

An Explanation of Benefits (EOB) is a document from the insurer after a claim is processed, detailing services, billed amount, insurer payment, and patient responsibility. It is not a bill, but summarizes how costs were covered and any outstanding patient liability. Reviewing the EOB helps verify billing accuracy and understand benefit application.

Coverage gaps can lead to unexpected expenses. For instance, purely cosmetic procedures are generally excluded. Certain pre- or post-operative therapies, recovery aids, or out-of-network provider charges might not be fully covered, increasing out-of-pocket expenses. Understanding network limitations and discussing payment plans with providers helps manage costs.