Is wisdom teeth removal under dental or medical insurance

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When my 17-year-old son, out of nowhere, had a terrible toothache late at night, I suspected it was wisdom teeth—but I wasn't overly worried. We had dental insurance, and I would get him in early the next morning for an evaluation. Little did I know that an unexpected dental bill was in my immediate future.

According to Dental Research Journal, an estimated 5 to 37 percent of people don't have wisdom teeth—and thus never experience complications from them. Wisdom teeth "are third molars and are the last set of teeth to erupt," Dr. Lesline Davis, dental surgeon and public health consultant, tells Health. "They erupt between ages 17 to 21, but some people don't develop wisdom teeth at all."

Also according to the American Dental Association, one of the first signs of a wisdom tooth that needs removal is pain, swelling, and stiffness of the jaw. This pain occurs because the wisdom teeth that have partially come through the gums can give bacteria a place to enter the gums and cause an infection. The wisdom teeth can become completely or partially impacted (trapped). This makes the impacted tooth difficult to clean, which increases the chances of dental cavities or a localized gum infection occurring in the area. This situation can also lead to pain, swelling and cyst formation as well as damage to other teeth.

Dental coverage is an essential health benefit for children, but not adults. This means that health insurance plans are not mandated to provide dental coverage as part of plans for anyone over 18 years old. According to the 2019 enrollment survey by the National Association of Dental Plans, since most wisdom tooth eruption and corresponding complications happen after the age of 18, and since about 25% of American adults are without dental insurance, over 33% of patients seeking wisdom tooth removal are left to shoulder this unexpected expense themselves.

Depending on the severity of the oral surgery needed to remove the wisdom tooth or teeth, your medical (rather than dental) insurance can possibly be billed—but this is dependent on which insurance codes are used when the claims are filed. Medical insurance will only help cover the cost if the oral surgery is deemed "medically necessary" for your overall health and wellness. The key here is the correct use of Current Dental Terminology (CDT) as established by the American Dental Association for identifying procedures provided to patients for oral treatment. It's possible that insurance will cover wisdom tooth removal as well as pay for any hospitalization and/or general anesthesia for the surgery—but it's also possible it won't. According to the Canada Dental Association, medical plans will not pay for treatments billed as CDT procedures.

The advent of the Affordable Care Act has allowed for many essential services to be covered under dental, but unfortunately wisdom tooth removal isn't considered in this lot. Most dental plans purchased through the Marketplace will cover 100% the cost of preventative care—such as cleanings, check-ups and x-rays. They will also cover 80% of basic treatments like fillings and 50% of more complex procedures such as root canals and crowns.

But with the known complications that can arise from untreated wisdom teeth, it's unfortunate that policy has yet to meet this medical necessity. Dr. Davis explains that an untreated impacted wisdom tooth can "lead to serious complications such as a swelling of the jaw and face that compromises breathing and requires hospitalization to treat, and infection spreading to your brain and to your bloodstream, which both can lead to death. It is important to note that this risk exists even if the pain subsides."

Dental HMO insurance plans will cover wisdom tooth removal in younger patients when recommended by a dentist. The catch is finding an oral surgeon who accepts your health insurance. In my son's case, the same state-subsidized dental coverage that covered his braces was almost useless for wisdom tooth removal. I spent an entire day calling every oral surgeon in NYC before I found one that would take his health insurance—but the earliest appointment was weeks away.

Ultimately, I paid $900 out of pocket to have my son's wisdom tooth removed. I decided against having him fully sedated because of the additional cost.

Registered dental hygienist Alwaine Fenton tells Health that there are numerous training facilities and care credit companies that offer affordable rates for dental care. Since routine cleaning and dental care for minors is easier to find, we asked Fenton specifically about reduced cost oral care and surgery options for adults. Fenton recommends the more popular options of using federally funded community health centers, and also United Way. United Way is seen as a one-stop shop for many social services, including dental care.

Fenton, however, is a big advocate for getting dental care, including wisdom tooth removal, from dental schools. He believes this is an excellent option because "even though students are practicing or training and may work slower with procedures taking longer to complete, there is reduced cost for dental treatment and students are closely supervised by licensed dentists."

When asked what disadvantages exist with using dental schools, Fenton mentioned that anyone needing emergency treatment would be inconvenienced because the wait time for appointments is usually long. Fenton reiterated that "an accredited dental school or dental hygiene school for quality and low-cost dental treatment is great because they are held to high treatment standards of the American Dental Association (ADA) and the American Dental Hygiene Association (ADHA)."

Another option for wisdom tooth removal is clinical trials. Some people hear the term "clinical trials" and assume increased risks—but that's not necessarily true. Based on FDA regulations, clinical trials are held to the strictest standards regarding compliance, as this is the basis on which many of their results are validated. The FDA published a draft guidance in 2013 that gives specific guidance to how a study sponsor must meet obligations to monitor or oversee a clinical study. Accredited medical organizations like the National Institute of Dental and Craniofacial Research perform clinical trials before a drug or therapy can be made available to the general public.

With most medical procedures, in the absence of excellent health insurance coverage and a big budget, access to information is your best bet. While not everyone will need wisdom tooth extraction, it is good to know (and explore) your options so that you can plan ahead in case you do.

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