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Is Gum Grafting Covered by Dental Insurance?

Maybe you’re a bit rough with your toothbrush or occasionally forget to floss. Maybe you've just had some bad genetic luck. Regardless, when your dentist peers into your mouth and suggests you need gum surgery to cover that sensitive spot where your gums have receded, you may be left wondering just how much this is going to cost you. This article explores dental insurance coverage for gum grafting, delving into the various factors that might affect your level of coverage.

What is gum recession and grafting?

Gum recession is a condition where the gum tissue that surrounds the teeth wears away or recedes, exposing more of the tooth or its root. This condition can result from several factors, including periodontal disease, aggressive tooth brushing, trauma, crooked teeth, genetics, vitamin deficiencies, tobacco use, poor oral hygiene, temporomandibular disorders, and hormonal changes. Left untreated, gum disease has been linked to heart disease, diabetes, and other serious inflammatory conditions.

healthy teeth recession gums

To correct recession, gum grafting involves transplanting a small section of tissue. The graft, generally taken from the roof of the mouth, is placed over the exposed root and helps prevent further recession and reduce sensitivity. Once the graft is in place, it protects against decay and improves the aesthetics of your smile.

Does insurance cover gum grafts?

Before you can determine if your insurance covers gum grafting, it's important to know what type of coverage you have. According to recent National Association of Dental Plans (NADP) research, a whopping 88% of the U.S. population has dental insurance coverage, which can fall under either a publicly funded or a commercial plan.

Publicly funded insurance plans, such as Medicare and Medicaid, generally do not offer dental care benefits. Original Medicare (Parts A and B) will not cover dental care, but if you purchase a Medicare Advantage plan (Medicare Part C), dental benefits are usually covered but will vary from plan to plan. Some Medicare Advantage plans will likely cover gum grafting, but you will need to check your specific policy.

Commercial dental insurance plans are most commonly offered through employers or purchased by individuals on the marketplace and include Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), and Indemnity plans. Big players in the commercial dental arena include Delta Dental, Cigna, Anthem BlueCross BlueShield, Humana Dental, Renaissance Dental, MetLife Dental, and United Healthcare. Each type of commercial dental insurance plan offers varying coverage levels, which is crucial in understanding if dental insurance covers gum surgery and what the cost of gum grafting with dental insurance will be.

  • Dental PPO. By far the most common type, comprising 86% of total enrollment in commercial dental insurance plans. Patients pay lower fees when they select a dentist within a network of providers and pay an agreed co-pay percentage for preventive, basic, and major restorative services. Procedure fees are set by an agreement between the insurance and the provider.
  • Dental HMO. Plan that is designed to keep costs lower. Patients choose or are assigned a primary provider within a smaller provider network and must have a referral to see a specialist. Emphasis is on preventive care, and out-of-network costs are not covered. Pre-authorization is often required before major dental procedures.
  • Indemnity. The most flexible of plans, this is a traditional type of insurance with usually no provider network. Patients can see any doctor of their choosing, and the plan will pay a predetermined percentage of service fees up to a maximum allowance.
Confident smile, covered costs
On dentalinsurance.com

Tiers of coverage

Most commercial plans allow you to choose from 2–3 levels of coverage. Basic dental plans cover preventive services, such as cleanings, exams, and X-rays. Many will also cover a portion of basic restorative services (fillings and extractions) but will not cover major procedures, like gum grafting.

More comprehensive plans at the middle and upper tiers will often follow something like the 100-80-50 plan: 100% coverage for preventive services; 70–80% coverage for basic restorative services; and 50% coverage for major services, which often include gum graft surgery. Patients pay the remaining balance.

Plans can vary greatly, so it’s important to check your specific dental insurance plan details for coverage specifics.

Factors affecting coverage for gum grafting

In addition to plan type and level of coverage, the extent of coverage for gum grafting by dental insurance can be influenced by several key factors.

Medical necessity vs. cosmetic procedures

The distinction between whether a procedure is a medical necessity or being done for cosmetic appeal can determine insurance coverage for gum grafting. Insurance plans generally cover procedures deemed medically necessary — those that restore function or prevent the worsening of a condition. Gum grafting is most often covered when it is performed to prevent tooth loss or treat periodontal disease.

Coverage limits and deductibles

Coverage for gum grafting can also be influenced by annual plan limits and deductibles set by the insurance policy. Most plans will set a maximum payout per year, which can range from $750 to $2,500. In addition, one usually needs to pay a yearly deductible, typically ranging from $0 to $75 of procedure fees, in addition to co-payments, before insurance will begin to cover your services.

Pre-existing conditions and waiting periods

Pre-existing conditions and waiting periods can further complicate coverage. If gum recession was noted before the insurance coverage began, some insurers might exclude the treatment from coverage. Waiting periods can extend from a few months to a year or more before major procedures are covered.

How to determine your coverage

When it comes to healthcare visits, no one wants to receive an unpleasant surprise when the bill arrives. It's always better to find out ahead of time if your insurance will cover your services so you can plan your finances accordingly. To verify whether your gum grafting is covered, consider these steps:

  1. Review your insurance policy. Thoroughly examine your dental insurance policy to understand coverage terms, including any exclusions or limitations concerning periodontal procedures.
  2. Consult with your dentist. Discuss with your dentist if the gum graft is medically necessary.
  3. Pre-treatment estimate. Obtain a pre-treatment estimate for gum grafting from your insurance company by having your dentist submit a detailed treatment plan.

Alternatives to gum grafting

If your gum recession is mild, there are alternatives to a surgical gum graft that may be enough to halt the progression. Alternatives include improved oral hygiene, scaling and root planing, and laser gum treatment. The best option depends on the severity of the recession, so it’s best to consult your dentist.

If you are experiencing significant gum loss, grafting might be the only viable solution. Unfortunately, the high cost of dental care, including preventive care and restorative treatment expenses, is an ongoing concern in the U.S. Ultimately, it’s better to try to prevent gum disease from ever happening.

Taking charge of your oral health

Preventing gum disease and recession requires proactive dental care. Regular dental check-ups and maintaining good oral hygiene practices, such as proper brushing and flossing, can significantly reduce the risk of developing severe gum issues. Additionally, incorporating oral probiotics, water flossers, and chlorohexidine rinses into your at-home routine may also assist in managing and preventing gum disease.

Whether gum grafting is covered by insurance depends on multiple factors, including the necessity of the procedure, the severity of gum recession, and the specifics of the dental insurance plan. By thoroughly reviewing your insurance details and consulting with dental professionals, you can gain a clearer understanding of your coverage options. Engaging in proactive oral health practices remains the best strategy to mitigate the need for gum grafting and other major interventions.

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