People often want to maximize their dental insurance benefits. However, it is difficult to determine which insurance covers cosmetic dental procedures. Dental insurance covers preventive and essential treatments. Some plans may also partially cover certain cosmetic procedures. Let us look at the cosmetic dental treatments that insurance might cover.

What is Cosmetic Dentistry?

Cosmetic dentistry is a term used to describe procedures that improve the aesthetics of teeth. It offers treatments and procedures to enhance your smile, whiten your teeth, and boost your confidence. Cosmetic dentistry offers solutions for chipped, cracked, discolored, or misaligned teeth. It can help you achieve your ideal smile.

The most common cosmetic dental procedures include:

  • Gum contouring
  • Tooth shaping
  • Dental veneers
  • Teeth whitening

How Dental Insurance Cover Works

Dental insurance covers some dental treatments. It also protects you from unexpected dental costs. To qualify for this insurance, you must pay a fixed monthly premium. The amount varies by provider, location, and plan.

The dentist's office often bills the insurance company directly, and the patient only pays a copayment for each visit or treatment. Dentists cannot provide exact information about insurance coverage and cannot estimate how much insurance will pay for a specific procedure. If you have questions about your coverage, contact your employer's benefits office. If you have questions about your coverage, contact your dental insurance provider or the health plan's third-party administrator.

Most insurance plans do not cover cosmetic dental treatments. These procedures are considered elective. You do not need them for medical treatment. However, your insurance may cover some costs if the procedure has a functional purpose.

Types of Cosmetic Dental Procedures and Insurance Coverage

Before starting the dental procedure, you should determine whether the cosmetic treatment is restorative or elective. Here is a detailed guide about the two types of cosmetic dental procedures.

     1. Restorative Dental Treatment

Dental insurance usually covers restorative procedures. These treatments include crowns, fillings, and, depending on the particular plan, dental implants. A restorative procedure is a crucial component of a smile makeover because it can improve the appearance of teeth. According to studies, roughly 20% of Americans have had at least one dental visit and at least one restorative dental procedure.

Composite fillings and porcelain crowns protect and repair teeth. They are made from materials that improve their appearance. These procedures are important for oral health. They also help make your smile more attractive. Insurance may cover the treatment if a dentist uses white dental restorations for a tooth injury.

     2. Elective Dental Treatment

Elective procedures are treatments carried out for cosmetic rather than health reasons. For example, if your teeth are healthy but you want to improve their appearance, any improvements made by the dentist are elective.

Dental insurance usually excludes elective procedures, such as teeth whitening and cosmetic veneers. However, exceptions exist. You may need correction if you have a defect in your front teeth. A crown might be too invasive. In that case, cosmetic bonding or veneers can be a less aggressive solution.

These treatments are optional. Your dentist may need to take photographs and X-rays. They might also make notes for the insurance company. These measures help to prove that the procedure is covered.

Common Procedures Covered By Dental Insurance

Some dental procedures are cosmetic and restorative and can be covered by insurance. Insurance will likely cover the cost when a dental procedure improves the function and health of the jaw, gums, and teeth. However, if the procedure is mainly aimed at beautifying the patient's smile, it will be classified as cosmetic and not covered by insurance.

The American Association of Oral and Maxillofacial Surgeons reports that 69% of American adults aged 35 to 44 have lost at least one permanent tooth. This loss is often due to gum disease, an accident, tooth decay, or failed root canal treatment. This loss affects both the appearance of their smile and the functionality of their oral cavity. A missing tooth can impair your ability to eat, speak, or chew effectively. Losing a tooth can negatively impact a patient's health.

A missing tooth can also harm the underlying jawbone structure. Once a tooth is lost, the jawbone in that area may deteriorate and weaken. Patients may also face bite issues because missing teeth disrupt the proper alignment. This can lead to significant health problems related to speaking and eating.

Some dental procedures are cosmetic but also help a patient's health. These include dental implants, bridges, crowns, and fillings.

Dental Crowns

Dental crowns improve the appearance of a smile by encasing a damaged or decayed tooth with a cap that appears natural and matches the color of nearby tooth enamel. They are often recommended for teeth that are significantly weakened or decayed. These crowns are tailored to imitate the color and shape of natural teeth, thus enhancing the affected tooth's function and aesthetics.

Crowns can be made from a variety of materials, such as:

  • Ceramic
  • Porcelain
  • Zirconia
  • Metal
  • Composite resin

You could have one fused to metal as an alternative to an all-porcelain dental crown. Your dentist will take into account several factors when choosing the material for your dental crown, including:

  1. The tooth’s position
  2. How much of your teeth will be visible whenever you smile
  3. Where your gum tissue is located
  4. Function of the teeth that require dental crowns
  5. How much natural tooth is left?
  6. Color of the adjacent teeth

You can also consult with your dental professional about your specific preferences.

Dental Implants

These replace missing teeth with artificial ones resembling natural ones, helping restore a patient's smile and confidence. A small titanium post secures the artificial tooth, known as a crown, to the jawbone. This artificial tooth can either be permanent or replaceable.

Dental implants blend seamlessly with the surrounding natural teeth once the supporting tissue and bone fuse and remain securely in place. Implants not only fill gaps but also help preserve bone tissue in the jaw, preventing the loss of more teeth. During and after the placement of dental implants, thorough hygiene is important to remove food debris and plaque from the area.

Dental Fillings

These are soft materials used to fill cavities in teeth. This procedure halts the progression of cavities after tooth removal and restores the tooth's function. Thus, fillings serve cosmetic and restorative purposes, making them eligible for insurance coverage.

A cavity often forms on the outer surface of a tooth due to trauma or decay. It is important to fill this cavity to prevent further deterioration, which could build up bacteria that could infect the inside of the tooth. If the decay reaches the inside of the tooth, more invasive treatment, such as a root canal, may be required.

It is easy to determine the need for dental fillings. If a particular tooth is sensitive when eating hot or cold foods and drinks, this may indicate that you need a filling. Additionally, you may require treatment if you feel pain while biting or notice that the tooth is rough, fractured, or chipped.

When you visit a dental professional for a filling, they will first examine the tooth to determine the cause of the problem and may take X-ray images if necessary. Before beginning the filling procedure, the dentist will apply local anesthesia to numb the affected tooth. They will then drill to remove the decayed material, which usually takes only a few minutes.

After the procedure, the tooth may be numb for several hours. While significant risks are uncommon, you should contact your dentist promptly if you experience any complications.

Dental Bridges

Placing dental bridges involves securing pontics, or artificial teeth, to nearby dental implants or natural teeth to fill gaps where teeth are missing. In addition to improving the functionality of the teeth, dental bridges also enhance your smile. Dental bridges are primarily divided into four types:

  1. Traditional dental bridges
  2. Maryland dental bridges
  3. Cantilever dental bridges
  4. Implant-supported dental bridges

Inlays and Onlays

Inlays and onlays are also called indirect fillings. Dentists use them when a tooth has mild to moderate decay. They are helpful when a tooth lacks enough structure to support regular fillings. Inlays are applied directly to the surfaces of teeth if the cusps are intact. A dental professional may use an onlay to cover the entire tooth surface if the cusp or a larger part of the tooth is damaged.

Traditionally, inlays and onlays were made of gold. Today, they are usually made from composite ceramic or porcelain in a lab. Dentists attach them to the teeth with adhesive dental cement. Both types provide support, strengthen teeth, restore their shape, and help prevent further decay.

Many cosmetic dentists perform these procedures. These treatments offer both cosmetic benefits and health advantages. Dental insurers often include them in their coverage. Insurance plans commonly cover bridges, implants, and crowns. Coverage usually depends on the specific reasons the patient needs these procedures.

If you are unsure whether insurance covers cosmetic dental treatment, talk to your insurer or dentist first. They can help you determine which procedures your insurance covers. You can also ask if certain conditions classify the treatment as medically necessary instead of elective. If your desired treatment qualifies for coverage, you can proceed with it.

Factors That Influence Insurance Coverage for Cosmetic Dental Procedures

Insurance companies may not always give clear answers about cosmetic dental procedures. Although some believe insurance excludes cosmetic procedures, it might offer coverage in certain cases. Insurance providers' assessment of cosmetic dental procedures can help determine whether they will be covered.

The main factors that impact insurance coverage for cosmetic dental procedures are listed below.

     1. Medical Necessity

Medical necessity is a major factor in determining whether your insurance company will cover your cosmetic dental treatment. Insurance companies usually categorize procedures as either necessary or cosmetic.

Medical necessity may be defined as the treatments, tests, or procedures necessary for maintaining or restoring health or treating diagnosed oral conditions as your insurance provider recommends. For a service to be covered under the insurance policy, it needs to fall within the ambit of medical necessity.

The insurance company may not have to pay the bill because it is covered. However, a copay, deductible, and coinsurance must be paid before the insurance company covers any service. Your insurance policy may also require you to pay certain expenses to reach your annual limit.

Therefore, if a dentist demonstrates the procedure's necessity for your oral health, there is a higher chance that insurance will cover it.

     2. Pre-Existing Conditions

Another significant factor in insurance coverage for cosmetic dental procedures is pre-existing conditions. Insurance coverage is more likely if a cosmetic procedure is necessary due to an injury or an underlying dental issue.

Examples of preexisting conditions include the following:

  • If your tooth is chipped from an accident, insurance might pay for dental bonding to fix its shape and function
  • If a tooth has been lost due to infection or injury, insurance may cover a dental implant or bridge to restore your ability to chew and maintain the alignment of surrounding teeth

In these cases, the cosmetic procedure helps restore one's appearance and ensure one's teeth' continued health and functionality.

     3. Policy Limits and Waiting Periods

Although your procedure may be covered, restrictions and waiting periods in your insurance policy could affect the amount you can claim. Most dental insurance policies come with yearly limits, which indicate the maximum amount they will cover in a year.

Waiting periods should also be considered. Even with coverage for the procedure, there may be a waiting period before insurance helps with payment. For example, certain insurance plans require a 6- to 12-month waiting period for major dental procedures, such as cosmetic treatments.

     4. Dental Plans That Include Cosmetic Coverage

Not every dental plan is the same. Basic dental plans cover essential procedures only, while premium or employer-provided plans may include additional services, such as cosmetic treatments. Certain plans might provide limited coverage or price reductions for elective treatments.

For example, a basic plan includes regular cleanings, fillings, and extractions. A more comprehensive plan includes crowns, bridges, or orthodontic treatments if needed for functionality. You should learn the details of your plan and seek advice from an insurance provider to understand which cosmetic procedures are covered. Certain plans may provide discounts that could lower the price of elective treatments, like teeth whitening.

Steps to Take If Your Insurance Plan Does Not Cover Your Cosmetic Procedure

If your insurance does not cover a cosmetic dental procedure, you may want to consider the following options:

  • Discuss the lack of coverage with your dentist and see if you can set up a payment plan that works for you
  • Review your local insurance options to see if they cover the procedure you are considering
  • If your insurance plan does not cover dental treatment, consider a discount dental program
  • If you can receive it from a participating dentist for less money
  • If none of these remedies work, you might want to consider delaying the surgery while you raise the funds for it

Alternative Options to Pay for Cosmetic Dental Treatments

If your medical insurance does not cover cosmetic dental procedures, you still have options to reduce the cost of these treatments. The following are the different funding choices that can help you cover the cost of your desired dental treatments.

Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs)

FSAs or HSAs can save money from your salary pre-tax for medical costs, including select cosmetic dental procedures. These accounts reduce your taxable income and help you save money on expenses. You can use FSA or HSA funds to cover some medical costs if a cosmetic procedure is necessary. This is a great way to reduce out-of-pocket costs for treatments like crowns, braces, or implants that insurance may not cover fully.

Financing Plans

Many dental clinics provide financing options to simplify the payment process for cosmetic treatments. These plans allow you to spread the cost of treatments over monthly payments, usually with low or zero interest rates. You can split the total expense into smaller installments that suit your financial situation rather than paying all at once. This allows individuals with limited funds to afford cosmetic dentistry services.

Dental Discount Plans

Dental discount plans offer savings on treatments, like cosmetic procedures, for individuals without dental insurance. These do not function as insurance plans. However, they grant discounts on dental services. You must pay an annual fee to enroll in the program and access reduced rates at participating dentists. It can help reduce the expenses of treatments not included in regular insurance policies, such as teeth whitening or veneers.

Exploring various payment methods offers more alternatives for cosmetic dental treatments. Opting for pre-tax savings, payment plans, or discount programs can help you obtain the perfect smile without exceeding your budget.

Find a Professional Cosmetic Dental Clinic Near Me

Many cosmetic dental procedures are not fully covered by insurance. However, some treatments may receive partial coverage if considered medically necessary. It is important to understand and discuss your coverage options with your dentist and insurance company.

At South Coast Dentistry, we can help you make informed decisions about your cosmetic dental requirements. We offer personalized sessions to review your options and determine which treatment could be covered by your insurance. Our team accepts most insurance plans, making achieving the smile you want easier. Call us at 949-274-9086 to discuss your cosmetic goals and payment options. We serve all areas in Aliso Viejo.