A gleaming grin can provide confidence, but cosmetic dental work often comes with a hefty price tag, so it is common for people to ask, “Does insurance cover it?” Although cosmetic dentistry is often viewed as non-essential, specific procedures exist that lie somewhere between cosmetic and essential, and are therefore covered. Whether it is teeth whitening or veneers, knowing what insurance may cover is important to avoid unexpected costs and plan for the smile you want. Some procedures, like crowns or fillings, considered medically necessary, may be covered by your plan, whereas purely cosmetic treatments usually are not.
Dental insurance may be intimidating, but understanding how it works puts you in a position to make informed choices. Are you willing to change your smile without spending a fortune? So, what cosmetic dental procedures may insurance cover, and open the door to a more confident and brighter you? The information below addresses each.
The Difference Between Restorative and Cosmetic Dentistry
The principle of insurance coverage of dental procedures is a matter of function. Insurers do not cover the treatment that is done purely based on aesthetics. However, they will cover the medically necessary procedures to restore the functionality of your teeth and ensure your oral health. This fundamental difference answers the question as to why some dental work is covered and others are not.
Restorative dentistry is a term used to describe treatment needed to repair caries or injury damage, restore the capacity to chew, treat disease, or stabilize the structural integrity of a tooth. These treatments aim to deal with a particular functional or health need. For example, a filling is restorative since it fixes a hole caused by decay. A crown is said to be restorative when it is necessary to cover a tooth with a significant fracture or a root canal to avoid any subsequent damage. Likewise, a bridge or implant to fill in a missing tooth is restorative as it restores the ability to chew and stops the shifting of other teeth.
Insurance plans often help cover the cost of these medically necessary procedures. Cosmetic dentistry, in contrast, is a treatment chosen by a patient simply to enhance the cosmetic aspect of their smile, without any health or functional need. They are regarded as elective procedures. These procedures include teeth whitening to make a smile brighter or veneers applied to structurally sound, healthy teeth to alter their shape or color. The treatments are not usually covered by dental insurance since they are not meant to treat a disease or restore a function. These procedures aim at improving aesthetics and not oral health.
Cosmetic Dental Procedures Insurance Covers
Aesthetic value can be attributed to many dental procedures with restorative and medically necessary purposes. Insurance coverage is determined by the necessity of the treatment, as opposed to the cosmetic result. The following is a breakdown of the typical procedures insurance companies could offer dental coverage:
Dental Crowns
The primary purpose of a crown is restorative, and it is one of the most common procedures that are paid for through dental insurance. A single crown may vary in cost considerably, usually running between $800 and $2,500 per tooth with no insurance, depending on:
- The material, including porcelain, zirconia, or metal
- The difficulty of the procedure
A crown is regarded as a significant restorative process, and it is usually paid for when it is a mandatory procedure to salvage or restore a tooth’s function. This is in situations where one tooth is:
- Fractured or broken several times, and a normal filling is not strong enough to provide structural integrity when fractured or broken several times
- Weakened following a root canal, and thus susceptible to cracking or breaking unless crowned
- Broken because of excessive decay that has not left enough sound tooth to hold a filling
- Needed to hold a dental bridge to replace a missing tooth
The role of the crown in all these situations is not only to enhance the tooth’s appearance but to repair and protect it, hence its insurance coverage status.
Orthodontics (Braces and Invisalign)
Braces and Invisalign are typically not covered if requested for cosmetic reasons, but may be covered in cases of documented medical necessity, especially for children. A complete treatment may cost between a few thousand dollars and several thousand dollars, depending on whether you use traditional braces (usually between $3,000 and $7,000) or Invisalign (usually between $3,0000 and $7,000). These expenses may be a considerable out-of-pocket cost.
Insurance is typically covered by a diagnosis of a severe malocclusion (a bad bite) with documented health issues. It is not merely the desire to have a straighter smile. Insurance companies seek medical conditions that prove the treatment is medically necessary. These problems can include:
- TMD, which is jaw pain caused by the incorrect bite that places stress on the temporomandibular joint
- Excessive or uneven tooth wearing, which may result in fractures, sensitivity, and nerve damage
- Problems with periodontal (gum disease) caused by severely crowded teeth that are hard or impossible to clean thoroughly
- Difficulty chewing or speech impediments that are directly related to the location of the teeth and the jaw.
Although these treatments bring a straight smile, the medical necessity prompts the coverage.
Veneers
Veneers are very thin shells and custom-made to enhance the tooth’s appearance. They are basically considered a cosmetic procedure. Because of this, they are not often insured. The cost of veneers can vary significantly depending on the teeth being treated, the material used, and the dentist’s expertise. Porcelain veneers can cost between $800 and $2,500 per tooth without insurance, thus making them a significant investment.
Nevertheless, in particular cases, a veneer may be clinically warranted and thus may be subject to coverage. This is done when a veneer replaces a chipped or broken part of the surface of a tooth to give it its original shape and strength. When this is the case, the procedure is not merely cosmetic, but a restorative treatment. Your dentist’s office should have clear records, including photos and x-rays, to show that the veneer is required to treat structural damage and not to alter the tooth’s appearance.
Dental Bonding
Dental bonding is a relatively cheap dental procedure, costing between $300 and $600 per tooth without insurance. It uses a resin material (tooth-colored) on a tooth. In the case of an insurance-covered restorative purpose, it is typically covered.
For example, when a tooth is chipped or fractured, dental bonding is a covered benefit since this dental procedure aims to restore the tooth’s original shape, save the inner nerve of the tooth, and restore the normal chewing function. Nonetheless, it is considered a cosmetic procedure when done on an otherwise healthy tooth purely on aesthetic grounds, like closing a small gap or altering the tooth’s shape to make a cosmetic smile. In this situation, the procedure is not usually covered. Coverage depends on the medically documented need, not the aesthetic result.
Dental Implants
Dental implants are regarded as the standard of care in teeth replacement, and a single implant costs between $3,000 and $6,000, including the implant, abutment, and crown. The coverage is based on the medical need of replacing a missing tooth, as it may lead to further problems, which include:
- Jawbone loss.
- Drifting of neighboring teeth.
- Problems with chewing and speaking.
Clinical Crown Lengthening (Gum Contouring)
Dental implants are becoming the gold standard of tooth replacement, and the main reason behind this is that the implant is a long-term and durable solution that feels and acts similar to a natural tooth.
Although a single dental implant may cost between $3,000 and $6,000, including the implant, abutment, and crown, it is not commonly covered, depending on the aesthetic result. Instead, it is supported by the medical necessity documented to replace a missing tooth and prevent a cascade of oral health issues.
Insurance companies tend to review the clinical necessity of an implant to ascertain coverage. The following are the main medical reasons that can make an implant eligible:
- To avoid bone loss in the jaw — The absence of a tooth results in the jawbone in that region no longer being used in chewing. In the absence of this stimulation, the bone starts to resorb or wear away, which may result in facial collapse and tooth loss. An artificial tooth root is a dental implant surgically embedded into the jawbone. It gives the bone the stimulation required to maintain its density and shape. It is an important functional advantage that cannot be provided by any other type of tooth replacement, including a bridge or a denture. However, this prevention of long-term bone loss is an excellent argument regarding medical necessity, as viewed from an insurance company’s perspective.
- To avoid drifting and shifting adjacent teeth — A missing tooth leaves an opening that can cause the nearby teeth to drift and move out of position. The movement may result in dental problems, like improper bite (malocclusion), a higher risk of decay in the newly created gaps, and gum disease. This space is filled with an implant that serves as a stable anchor to hold the surrounding teeth in their proper position. This preventative care is medically necessary to sustain the general health and alignment of the patient’s dentition.
- To regain the function of chewing and speaking — A lost tooth may seriously affect a person’s chewing and speaking abilities. It may cause ineffective chewing, depending on where the missing tooth is, and thus disrupt digestion or cause slurring and whistling during speech. An implant replaces the entire functioning capacity, enabling the patient to bite and chew with the same intensity as a natural tooth. A definite medical reason to undergo the procedure is this functional restoration.
Although the aesthetic advantages of a dental implant cannot be denied, insurance coverage still concentrates on how the dental implant can treat these underlying medical conditions. To increase the likelihood of a favorable coverage decision, patients and dentists need to collaborate to record and demonstrate the functional need of the implant.
How to Formally Request and Justify Coverage
A procedure code is usually not sufficient to secure dental insurance coverage. You should officially explain why the treatment is medically necessary. This proactive process increases the likelihood of a claim being approved and prevents unforeseen expenses.
The primary evidence to be considered by the insurers is the clinical documentation provided by your dentist. That is why it is so important to have detailed notes, diagnostic X-rays, and intraoral photos. X-rays can display the degree of a cavity or crack, whereas photographs can illustrate the damage to a tooth. These records will offer the objective evidence that an insurer requires to understand the clinical need for a procedure.
If a claim is likely to be challenged or denied, your dentist can provide a Letter of Medical Necessity. It is an official document that describes the patient’s clinical diagnosis and explains why the prescribed treatment is necessary. The letter directly links the proposed procedure with a specific health condition, hence the justification that it is a restorative procedure, not a cosmetic one. This is a strong coverage argument document.
A predetermination of benefits is the most valuable step you can make. It is an official document that your dentist will send to the insurance company before any treatment. It is a procedure of sending the proposed treatment plan and all the supporting materials, including X-rays and photos, for a formal review. The insurer, in turn, estimates in writing how much they will cover and how much it will cost you out of pocket. This step gives you a preview of your coverage, allows you to make an informed decision, and helps you avoid any financial surprises. Although it is not a guarantee of payment, it is a reliable method of ensuring you are covered.
Common Policy Limitations
Although dental procedures may be deemed medically necessary, some policy restrictions may affect your coverage. When planning treatment, it is critical to be mindful of these challenges to avoid out-of-pocket expenses and unwanted surprises.
The Missing Tooth Clause
The missing tooth clause is a pre-existing condition that limits a dental insurance plan. This provision means that the plan will not reimburse the price of replacing a tooth extracted or already missing before the policy’s effective date. For example, say you lost a tooth a year ago before enrolling in a new plan. That plan may not cover an implant or bridge to replace it, even though this treatment is medically necessary to restore function.
Waiting Periods
Most dental insurance policies, particularly for new enrollees, have waiting periods before some of the benefits can be used. Although preventive care like cleanings may not have a waiting period, more substantial work, including crowns, bridges, and dentures, will generally have a waiting period of 6 to 12 months after the date the policy is taken. This will save people from purchasing a plan only to cover a costly, urgent operation and dropping the policy.
Annual Maximums
The annual maximum is the highest amount a dental insurance plan will pay in a given year for covered procedures. When this cap is exhausted, you must pay 100% of additional expenses, including medically necessary procedures. The average annual limit is between $1,000 and $2,000, and it can be easily exceeded with one major procedure like a dental crown or implant.
Find a Cosmetic Dentist Near Me
A beautiful smile does not have to cost you a fortune, and using the cosmetic dental procedures covered by insurance can open the door to a brighter smile. Purely aesthetic treatments might not be possible, but medically necessary procedures can be, and they serve the dual purpose of being functional and beautiful. Knowing your plan’s coverage will enable you to make informed decisions on your dental care.
Do not let uncertainty stop you from achieving a confident smile. Call The Hawthorne Dentist to receive professional advice on insurance-covered services. Call us today at 310-775-2557 and book your next appointment with us.
