Does Health Insurance Cover Orthognathic Surgery?

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   Marlin McKelvy

   President, Consumer Directed Benefit Solutions, Memphis, Tennessee

   This procedure exists in one of those gray areas and the answer will differ depending upon the underlying need for this surgery to the jaw.  From a health insurance perspective the key issue is whether the terms "medical necessity" versus "cosmetic" apply to the need for this surgery.  If a clear case for medical necessity for this procedure is established you can generally expect most health insurance plans to cover it.  However, the line between medically necessary and cosmetic can often be in the eye of the beholder so you should not expect a health insurance company to routinely approve such a procedure and you should definitely not proceed with scheduling such a procedure without checking with your health insurer first and getting clear approval.  Often the insurance carrier will want written documentation from one or more health care providers that there is a medical necessity for this procedure to be performed.  It is also likely that the insurance carrier will want to make sure that other, less drastic approaches have been exhausted before they will approve this procedure.  Some of these options may include orthodontia treatment which will fall under the coverage of dental insurance (if you have it) not your health insurance.  As a general rule, just because the jaw issue leads to a misalignment that may keep you off of a magazine cover or presents the member with self-image problems will not be seen as justification for covering this procedure.
   

   Answered on April 22, 2014

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