Do you have a chip from a long-forgotten childhood mishap, teeth that have yellowed with age, or a gap that has lowered your confidence? If these are issues you experience, you could be willing to get a change but are unsure whether your dental insurance will cover the cosmetic procedures. This insurance uncertainty bothers many patients seeking dental procedures, but they fear the cost.
Some dental insurance plans could have clauses and exceptions that leave you wondering what is covered. Although purely aesthetic treatments are not typically included, most procedures that improve or restore teeth functionality are covered. Medical necessity is one significant factor determining whether a person will be covered by insurance.
In this article, what can be covered as a cosmetic procedure is demystified, and these include:
Dental Crowns
A dental crown is a tooth-shaped, made-to-fit cover surrounding a damaged tooth, and its original shape, size, and strength are restored. Though the outcome is that of a tooth that appears natural and clean, insurance companies are concerned with the medical purpose of the crown. Crowns are nearly always covered as a necessary restoration.
When necessary, a crown may be included in your dental plan to save a tooth that has become weak or structurally damaged. This usually follows a root canal surgery that may leave a tooth weak. Crowns that restore a tooth that is severely decayed, cracked, or broken are also generally covered by insurance since the crown prevents further damage and possible loss of the tooth.
In addition, crowns play a significant role in a dental bridge that replaces a lost tooth. In this respect, they are regarded as an essential component of a restorative treatment. Crowns are also commonly used when your teeth have been severely worn down by grinding (bruxism) to the extent that your bite and chewing capability are compromised.
But if all you desire is to alter the shape or color of a healthy and functional tooth, a crown request will be considered merely cosmetic and will not be reimbursable by your insurance plan.
Dental Bonding
Dental bonding is a flexible and cost-effective process in which a skilled dentist applies a tooth-colored composite resin and molds it to a tooth. It is a great remedy for minor cosmetic blemishes, although its true worth to an insurance company is its capability to fix what needs to be fixed. Bonding is almost always a restorative procedure used to repair damage and is generally covered.
Your insurance will likely pay for dental bonding if the procedure is conducted to restore a chipped or broken tooth, such as in a car accident or injury. The reason is that when the chip or crack is sealed, the bacteria cannot enter the tooth and cause its damage, and the tooth's integrity is restored. The same applies to you when you have a cavity.
Your dentist can apply the same composite resin to fill the cavity, a typical restorative procedure covered by most dental plans. The aesthetic advantage is that the filling is the same color as your natural tooth, but the main reason is to cure the decay.
On the other hand, when you choose to have dental bonding to fill in a small, healthy space between your front teeth or seal a small stain on an otherwise healthy tooth, that is elective. In such cases, since there is no medical necessity behind the treatment, chances are high that your insurance plan will not cover it.
Dental Bridges
A dental bridge is a fixed restoration to replace one or more lost teeth. It is done by attaching an artificial tooth to the natural teeth or dental implants on one side of the gap. Although the cosmetic advantage is evident initially, it restores a complete smile. Therefore, the central role of a bridge is purely functional and restorative.
A bridge is necessary to regain your normal bite or ability to chew food normally, to keep the rest of your face in a natural shape, and to keep the other teeth in place. This can cause bite issues and other problems. These are all well-documented health reasons why a dental bridge can be regarded as a standard type of restorative treatment and is virtually always covered by a dental insurance plan.
Dental Veneers
Veneers are slim, custom-made shells, usually made of porcelain, that are glued to the front of teeth to produce a perfect camera-ready smile. They are universally considered the pinnacle of cosmetic dentistry, so most insurance plans classify them as an elective procedure and do not cover them. Nonetheless, there are certain, but less frequent, scenarios in which veneers can be considered medically necessary, and the possibility of partial coverage can be opened.
Insurance companies can consider paying part of the price of veneers as a restorative step. To illustrate, when a tooth is fractured or a great deal of it is chipped off in an accident, a veneer is an option to reshape it and prevent further harm. Another example is where there is a severe erosion of the outer layer of the tooth, the enamel, causing the tooth to be sensitive or exposed to decay. Veneers in these cases may require a protective coating, and your dentist can record this medical necessity for your insurance company.
You should learn to control your expectations because such cases are exceptions, not the rule. When you have veneers just to make healthy teeth look better, to alter their shape, to fix minor crookedness, or to seal gaps, the treatment will be considered purely cosmetic, and you can expect to pay the full cost from your pocket.
Inlays and Onlays
Also known as partial crowns, onlays and inlays are high-strength, custom-made restorations employed to salvage the tooth whose damage is too large to warrant a simple filling but not too large to warrant a full crown. They are generally made of tooth-colored porcelain; therefore, they merge with your natural smile.
Although they offer an excellent cosmetic outcome, they are primarily used to re-establish the integrity and the strength of a moderately damaged tooth. Because their purpose is evidently curative, inlays and onlays are virtually never categorized as an elective procedure, and they are easily included in insurance programs to a comparable degree as crowns.
Dental Implants
The dental implant is the most permanent replacement for a missing tooth. It is used as a fake tooth root implanted into the jawbone to give a solid base to a replacement tooth or crown. Although the outcome of implants is better aesthetically, they play a restorative role and thus can be covered by insurance as long as they are medically necessary.
Your insurance plan may cover dental implants when a tooth is lost because of disease, decay, or an injury. When this happens, the tooth will need replacement to regain normal chewing functions, which can affect your general nutrition and digestive system. Moreover, tooth loss can cause serious medical implications, including the displacement of the adjacent teeth and the loss of the jawbone.
Since an implant makes the jawbone active and helps to avoid bone loss, an implant is sometimes regarded as a mandatory procedure to keep your teeth and jaw healthy. Coverage may also be granted to those with congenital conditions who are born without some teeth.
The secret to getting the coverage is to prove that the implant is not solely cosmetic but is also necessary to your general oral health and functionality. This is important because your dentist will furnish your insurance company with much documentation, including X-rays and a letter of medical necessity.
Orthodontics (Aligners and Braces)
Orthodontic procedures such as braces and clear aligners produce beautiful, straight smiles. Nevertheless, they qualify to be covered by insurance, as they can fix functional issues associated with their teeth. Although an aligned smile is an excellent result, what really matters to insurance companies is the issue of whether the treatment is medically necessary to enhance your oral health.
In most cases, when orthodontic treatment is needed to fix a significant malocclusion, commonly referred to as a bad bite, the orthodontic treatment will be covered. This is accompanied by issues such as a severe overbite, underbite, or crossbite that disrupts your ability to chew correctly, speech impairment, or painful jaw aches and temporomandibular joint disorders commonly referred to as TMD.
Making teeth more challenging to clean and prone to cavities and gum disease, correcting severely crowded or misaligned teeth can also be considered medically necessary. Insurance will also be more likely to cover an injury that leads to misalignment.
However, the treatment will be considered cosmetic if you wish to have braces or aligners to fix some minor crookiness or small gaps to look good and have no underlying functional health problems. There is very little likelihood of insurance coverage in such cases.
The Deciding Factor
Before you can learn about your dental insurance benefits, you must first understand the fundamental differences that providers have drawn between cosmetic and restorative dentistry. It is their primary classification according to which they analyze claims and determine what is covered. What is really important is the purpose of the procedure, rather than the procedure itself.
You undergo cosmetic procedures just to make your teeth and smile look better. Consider the treatments meant to change the color, shape, size, or alignment of otherwise healthy teeth. These are generally not included, as dental insurance is designed to combat health conditions rather than to appeal to preferences.
Restorative dentistry, on the other hand, revolves around medical treatments that are necessitated. A procedure is said to be restorative or medically necessary when it is needed to diagnose or treat an illness, injury, or disease. This involves the restoration of a broken or decayed tooth or a missing tooth to restore the function of chewing or treating an infection.
These procedures are supposed to be covered by insurance plans, as they are necessary to keep your mouth healthy and avoid more serious issues that will arise. The cosmetic enhancement that frequently goes hand in hand with a restorative procedure is a bonus, but the health condition makes it claimable.
Procedures That Are Not Insured
Some of these procedures occupy a gray zone between cosmetic and restorative procedures, whereas others are entirely regarded as elective by dental insurance companies. Knowing the services generally included in this category can allow you to budget your money and not be caught off guard. When there are no medical or health advantages to a procedure, but it is used to make oneself more attractive, you should anticipate paying the cost yourself.
An example of purely cosmetic treatment is teeth whitening. Whether you choose an in-office professional procedure or a kit to do it at home, the idea is simply to make your teeth look lighter. Insurance plans do not cover whitening services because discolored teeth do not pose any health risk.
Another procedure not commonly covered on cosmetic grounds is gum contouring or a gum lift. When you have what is commonly called a gummy smile, and the teeth look short due to extra gum tissue, a dentist can re-sculpt the gum line to produce a more balanced and attractive appearance. However, since this is not a treatment for an ailment or an oral operative procedure, it qualifies as elective cosmetic surgery.
As discussed above, veneers applied to healthy teeth to transform your smile are not covered. Insurance will not add to the cost when you want to change the color, shape, or size to look more similar.
How to Confirm if Your Cosmetic Dental Procedures Are Covered
The dental insurance world may be confusing, but you can make clear and proactive choices to make sense of your benefits and prevent unwanted surprises. The ideal way to make positive decisions regarding your dental care is to be informed and prepared. Use this action plan to decide your policy's cover before committing to treatment.
Check Your Insurance Policy
The first thing you need to do is get acquainted with your dental plan's particulars. Each policy is varied and has rules, limitations, and exclusions. Find your “Evidence of Coverage” document or your “Summary of Benefits” document, which may be found online through your provider's member portal. Read the parts on restorative procedures and cosmetic services.
Note the percentage of coverage in various types of treatment, your maximum coverage per year, and the deductible. Call your insurance provider's customer service line if the language puzzles you. Get them to provide information to you directly to determine whether the specific procedure you are considering will be covered and under what conditions it will be covered.
Get a Pre-Treatment Estimate
This is the most crucial action to prepare a clear financial picture. A pre-treatment estimate, or pre-authorization or pre-determination, is a request that your dentist's office forwards to your insurance company on your behalf. This request specifies the procedure codes for your intended treatment plan and any supporting materials, such as X-rays or notes, to explain why the medical necessity underlies the procedure.
Your insurance company will review this information, and a document will be sent back to you with details of what they will cover and your estimated out-of-pocket cost. This will help eliminate the guesswork, and you can proceed with the full knowledge of your financial obligation. It is free and the most effective way to avoid unpleasant surprises once your treatment ends.
Discuss Financing Alternatives
If you realize that your insurance does not provide the procedure you would like, or the out-of-pocket cost is higher than you can comfortably pay now, do not despair. Several dental practices are determined to make care affordable and provide numerous financing options. Discuss your options with the office's financial coordinator. Many offices have in-house payment plans where you can pay the cost over many months.
The other common alternative is third-party financing, typically provided by companies like CareCredit, which act as a credit card for healthcare costs and tend to have low- or no-interest promotional periods. The money in a Flexible Spending Account, also called FSA, or in a Health Savings Account, also called HSA, may be used to cover your treatment with pre-tax money.
Locate a Cosmetic Dental Clinic Near Me
The coverage is usually based on whether a cosmetic dental treatment is medically necessary to restore functionality and health, and is not for aesthetic enhancement. Crowns, bonding, and implants are often covered under insurance to repair a damaged tooth, cure a dental problem, or support the structural integrity of your mouth.
Understanding and navigating deductibles, annual maximums, and pre-authorizations can be challenging. You should consult your cosmetic dentist in the City of Fullerton to ensure you receive the fullest insurance benefits.
At Tayani Dental Group, we can supply the required paperwork to your insurance company and assist you in knowing all of your choices, both treatment-wise and payment-wise. You can call us today at 949-741-0795, and we will help you understand if your dental procedures are medically necessary or purely cosmetic.
