Patients needing orthognathic surgery wear orthodontic braces before and after the procedure. Therefore, you may need your health and dental insurance to honor claims to minimize out-of-pocket costs.
The two programs work oppositely.
You can get your health insurance to pay for the corrective jaw surgery by showing the medical necessity. Still, you may face challenging obstacles in getting the plan to cover the orthodontia.
Your dental insurance is more likely to pay for the braces if your plan includes orthodontia benefits, but it is less likely to cover the entire cost of the corrective jaw surgery.
Health Insurance Coverage
The only way to get health insurance to cover orthognathic surgery is to prove that the corrective jaw procedure is medically necessary. Shopping around for a different plan is not the answer.
Cosmetic Procedures
First, you will never get your health insurance to pay for orthognathic surgery when the procedure is cosmetic: reshape or enhance the size of the chin to restore facial harmony.
Cosmetic jaw surgery is never medically necessary. Therefore, expect to pay the entire procedure cost out-of-pocket with no help from your insurance.
Medically Necessary
Learning when orthognathic surgery is considered medically necessary is crucial to getting health insurance for corrective jaw procedures. Check your policy for its precise definition, which may be similar to this statement.
“Medically necessary means the operative procedure treats an illness, non-biting injury, condition, disease, or its symptoms or is an integral part of a covered service.”
Necessary Surgery
First, your health insurance might consider orthognathic surgery medically necessary when it treats an illness, non-biting injury, condition, disease, or its symptoms.
For example, BCBS of North Carolina lists these reasons.
- Correction of significant congenital (apparent at birth) deformity
- Restoration of function following treatment for substantial accidental injury, infection, or tumor
- Treatment of malocclusion that contributes to recalcitrant temporomandibular (TMJ) syndrome
- Signs and symptoms are present for at least four months
- Symptoms are unresponsive to conservative measures for four months
- Treatment of malocclusion that contributes significantly to disorders unresponsive to 4 months of non-surgical therapy
- Speech abnormality
- Malnutrition
- Significant intraoral trauma while chewing
- Treatment of documented obstructive sleep apnea
Necessary Orthodontia
Second, your health insurance might not consider orthodontia medically necessary as an integral part of a covered service (orthognathic surgery) even though you need braces before and after the procedure.
Medically necessary orthodontics is more common for children than adults because correcting congenital deformities is best before the jawbone stops growing and hardens.
Check your policy to confirm coverage. For instance, the BCBS document cited above states, “braces and any other orthodontic services are considered dental in nature and are not covered as a medical benefit.”
Sample Letter
Having your oral surgeon compose a letter of medical necessity beforehand is the best way to get health insurance to cover orthognathic surgery and the accompanying orthodontic work.
Submit the document to the issuing company for pre-certification. In the letter of medical necessity, include as many of these elements as possible.
- Patient name and member ID number
- SOAP Notes (Subjective, Objective, Assessment, Procedure)
- Summary of medical history and diagnosis
- Rationale for treatment
- How it treats a disease or illness
- Why is it consistent with the applicable standard of care
- Proposed operative report
- Appropriate ICD-10 and CPT codes
- Prognosis or expected outcome
Medicaid Coverage
Finally, asking whether Medicaid covers orthognathic surgery is the wrong question because the publically-funded insurance program has two elements with vastly different criteria.
- Medicaid covers orthodontic braces using different standards
- Adults must have a medically necessary reason (rigorous)
- Children must have a handicapping malocclusion (lenient)
- Medicaid is health insurance in all fifty states and might pay for jaw surgery when deemed medically necessary (see above)
The better question is how you get Medicaid to pay for orthognathic surgery and the accompanying orthodontic braces. You must submit a well-documented letter of medical necessity for pre-certification for both services.
Dental Insurance Coverage
If you have a plan that includes orthodontia benefits, getting dental insurance to pay for orthognathic surgery is possible. Plus, you must demonstrate a Class 3 Malocclusion, a different definition for medically necessary oral care.
In other words, your dental insurance may honor claims when health insurance does not because the criteria differ, plus more (the braces).
Orthodontic Insurance
Dental insurance with orthodontic benefits can help pay for orthognathic surgery in two ways: a surgeon and orthodontist must provide treatment.
- Orthodontic braces before and after the procedure
- The surgery to correct a Class 3 Malocclusion in adults
However, many dental insurance plans do not include benefits for orthodontia (addressing improper tooth and bite alignment issues) and will not pay for either of these treatments. What should you do?
Purchase adult orthodontic insurance and delay treatment until the two-year waiting period ends. Your jaw alignment issues probably did not happen overnight, so planning your steps could make a big dent in overall costs.
Remember, your health insurance may pay for the surgery while excluding claims for the braces. In these cases, the orthodontic benefit is crucial to cover the full spectrum of your treatment.
Malocclusion Classes
Learning when corrective jaw surgery is considered medically necessary is crucial to getting dental insurance with orthodontic benefits to pay for orthognathic procedures. Check your policy for its precise definition.
For plans with orthodontic coverage, the medically necessary definition could revolve around a malocclusion classification system described by Mount Sanai.
- Class 2 malocclusion, called retrognathism or overbite, occurs when the upper jaw and teeth severely overlap the bottom jaw and teeth.
- Class 3 malocclusion, called prognathism or underbite, occurs when the lower jaw protrudes or juts forward, causing the lower jaw and teeth to overlap the upper jaw and teeth.
Have your oral surgeon compose a letter of medical necessity documenting the malocclusion class with images, measurements, impressions, appropriate ICD-10 and CPT codes, and the expected outcome.
Submit the letter to your dental insurance company for pre-certification.
Annual Maximum
Even if you can get your dental insurance with orthodontia benefits to cover orthognathic surgery, the annual maximum benefit might limit what the plan pays, leaving you with most of the average $30,000 cost.
Timing the procedure steps ideally can help you avoid maxing out your dental insurance. For instance, following this four-year treatment plan, you might get the most from a plan with a $2,500 annual maximum.
- Year one: pre-surgery braces
- Year two in November or December: lower jaw surgery (mandible)
- Year three in January or February: upper jaw surgery (maxilla)
- Year three and four: post-surgery braces
The annual maximum limits what your plan will pay for covered services in a calendar year. By spreading the procedure over four years, you can quadruple your benefits.
