Wisdom teeth removal is a standard dental procedure that many people will need at some point. However, the cost of this procedure can be a concern for many patients.
Whether wisdom teeth removal is covered by dental or medical insurance is a commonly asked question, and the answer depends on one critical factor.
This article will discuss the differences between bone-impacted and gum-impacted third molars and how medical necessity can affect which plan will honor claims.
You will also learn what happens when both plans cover the procedure. The secondary payer coordinates benefits with the first.
When Medical Covers Wisdom Teeth Removal
Health insurance covers bone-impacted wisdom teeth removal when medically necessary. This definition includes care from non-biting accidents, some diseases, and treatments as part of other covered services.
Medical insurance has no waiting period for the procedure because most people have coverage. If someone does not, the Affordable Care Act requires new plans to cover pre-existing conditions immediately.
Primary Payer
When medical insurance covers the extraction of bone-impacted wisdom teeth, it is the primary payer. The primary plan pays first as if it were the only coverage.
Bone-impacted wisdom teeth removal charges are near zero when your medical insurance covers most of the charges. A lack of dental insurance is immaterial in this instance.
Each plan’s cost-sharing features differ, such as deductibles, copayments, and coinsurance. However, you will never encounter an annual maximum benefit capping payment.
Therefore, work closely with your oral surgeon to develop a letter of medical necessity, including x-rays and other diagnostic images showing your third molars embedded in the jaw. Submit the letter for pre-approval.
Bone-Impacted
Medical insurance typically covers most costs associated with the extraction of bone-impacted wisdom teeth because they meet the medically necessary definition. Third molars embedded in the jaw can cause pain, swelling, infection, decay, and develop cysts.
This more complicated procedure requires the skills of an oral surgeon and deep sedation (general anesthesia), resulting in higher initial charges. Therefore, it is crucial to find a provider who participates in your plan’s in-network network.
Maxillofacial surgeons accepting Medicaid (or your specific health insurance plan) agree to charge the allowed amount, a significant discount from retail prices that other patients must pay. You do not want to forgo these typical in-network savings.
- Retail price: $1,900
- Surgical extraction of four third molars
- Therapeutic drug injection (Dexamethasone)
- Deep sedation (general anesthesia)
- Panoramic radiographic image
- Allowed amount: $1,300
Medicaid
We must also address when Medicaid covers wisdom teeth removal because, in many instances, this publicly funded program for low-income families is medical and dental insurance.
Medicaid covers wisdom tooth extraction differently for adults and children in every state, reflecting its dual nature and the diversity of our country.
| Health | Dental | |
| Children under 21 | Bone-impacted nationwide | Gum-impacted nationwide |
| Adults over 21 | Bone-impacted nationwide | Gum-impacted in 25 states |
Medicaid does not cover dental work for adults uniformly. Although a federal program, each state determines what oral care benefits to support through its budget. Therefore, some individuals over twenty-one will have coverage, while others will not.
When Dental Covers Wisdom Teeth Removal
Most dental plans cover wisdom teeth removal after your health insurance processes claims submitted by your provider. It is the primary payer for gum-impacted extractions and secondary for medically necessary services.
Gum-Impacted
Dental insurance typically covers most costs associated with the extraction of gum-impacted wisdom teeth as the primary payer because they do not meet the medically necessary definition.
A general dentist can perform these elementary extractions in their office using oral sedation (nitrous oxide or laughing gas), charging lower fees than an oral surgeon might.
Payment plans for wisdom tooth extractions can make these services more affordable by spreading costs over time. Most dental insurance leaves patients with significant unreimbursed expenses through exclusions and other limiting features.
- Waiting period for major services
- Annual benefit maximum
- Coinsurance (% of allowed amount patient owes)
Secondary Payer
When dental insurance covers bone-impacted wisdom tooth removal, it does so as the secondary payer. The secondary plan only pays the costs that the primary insurance did not cover.
As the secondary payer, your dental plan coordinates benefits with your medical insurance, filling in where the first coverage left off.
- Bone-impacted left-over expenses
- Annual deductible
- Coinsurance and copayments
- Out-of-network charges above the allowed amount
- Gum-impacted total expenses
- Extractions
- Oral sedation
- X-rays
As you can see, the cost of wisdom teeth removal with insurance can range widely, even for patients with both types of coverage.
- Low-end: you choose an in-network provider for bone-impacted extractions, and your dental insurance coordinates benefits as the secondary payer
- High-end: an out-of-network dentist pulls four gum-impacted third molars, and your annual benefit maximum limits claim payments
