Is Jaw Surgery Covered by Insurance?

Jaw surgery, also known as orthognathic surgery, is a big deal. It fixes jaw misalignments, facial imbalances and functional issues like trouble chewing, speaking or breathing. When people consider this surgery they ask is it covered by insurance? The answer is mostly dependent on medical necessity of the procedure, your insurance plan and the documentation.

Medical Necessity: How It Affects Insurance Coverage

Insurance will cover jaw surgery if it’s medically necessary. That means the surgery has to address functional issues that affect health and quality of life. Common examples are severe jaw misalignment, sleep apnea, trouble chewing, speaking or swallowing.

To show medical necessity your oral surgeon or orthodontist will need to provide a detailed diagnosis and treatment plan. This includes X-rays, medical records and a letter explaining why the surgery is necessary for your health. Insurance companies will cover surgeries that improve basic health functions not cosmetic enhancements.

Types of Jaw Surgery Covered by Insurance

Insurance will cover jaw surgeries that correct functional issues. These are:

• Maxillary Osteotomy (Upper Jaw Surgery): Fixes upper jaw misalignments like overbites or open bites.
• Mandibular Osteotomy (Lower Jaw Surgery): Fixes lower jaw problems like underbites.
• Genioplasty (Chin Surgery): Fixes jaw related chin deformities.
• Surgery for Sleep Apnea: Treats breathing problems caused by jaw structure.
• TMJ Disorder Surgery: Relieves pain and restores jaw function for severe cases.
• Reconstructive Surgery for Congenital Defects: Fixes birth related issues like cleft palate.

Check with your insurance what procedures are covered and under what conditions as some may be excluded if considered cosmetic.

Documentation Needed for Insurance Approval

You will need:

• Diagnostic images (X-rays or CT scans).
• Letter of medical necessity from your surgeon explaining the health risks without surgery.
• Written treatment plan explaining the benefits of the procedure.
• Supporting documents from your general dentist or other healthcare providers.

Incomplete or inaccurate paperwork can delay or jeopardize your claim. Be proactive and ensure all required documents are submitted correctly and on time.

Preauthorization for Coverage

Preauthorization is required before surgery. This means getting approval from your insurance company to make sure the procedure meets their coverage guidelines.

Your surgeon’s office will handle the preauthorization request by submitting all the necessary paperwork, including medical necessity and treatment plans. Preauthorization doesn’t guarantee full coverage but will tell you what your insurance will cover and what out of pocket costs.

Not getting preauthorization can result in denied claims so make sure to do this well in advance of surgery date.

How to Appeal an Insurance Denial for Jaw Surgery

If your claim is denied you have the right to appeal. Here’s how:

1. Understand the Denial: Read the explanation of benefits (EOB) or denial letter to see why the claim was denied.
2. Get More Evidence: Work with your surgeon to get more medical records or a revised letter of medical necessity.
3. Submit an Appeal: Write a detailed appeal including all supporting documents and reasons for denial.
4. Request a Peer Review: Ask for your case to be reviewed by a doctor within the insurance company.
5. Escalate if Necessary: If the appeal is denied, consider an independent medical review or a lawyer.

Persistence pays off. Many initial denials are overturned with the right paperwork and follow up.

Other Options if Insurance Doesn’t Cover the Procedure

If insurance doesn’t cover your jaw surgery consider:

• Payment Plans: Many providers offer payment plans.
• Medical Financing: Look into third party healthcare loans with low interest rates.
• HSA or FSA Funds: Use pre-tax savings accounts for eligible medical expenses.
• Charitable Organizations: Some non-profits offer financial assistance for medically necessary surgeries.
• Crowdfunding: Platforms like GoFundMe can help you raise money from friends and family.
• Negotiation: Ask your surgeon about discounts or bundled payments.

These options can help with costs and make the procedure more affordable even without insurance.

Conclusion

Jaw surgery can be life changing and improve health and quality of life. While insurance coverage depends on medical necessity and proper paperwork, understanding the process and being prepared will increase your chances of approval. If you’re facing financial barriers, payment plans and medical financing can help.

Talk to your surgeon and insurance company first. Then you’ll be prepared. 🙏