Medicaid in New York covers wisdom teeth removal, but only when the procedure is deemed medically necessary. The program, delivered through Medicaid Managed Care Organizations (MCOs) or the Fee-for-Service program, adheres to state guidelines for all dental procedures. Coverage depends on a detailed clinical assessment and a mandatory administrative review process.
General Dental Coverage under NY Medicaid
New York State provides broad dental benefits to Medicaid enrollees. The coverage includes routine preventive care like cleanings, examinations, and X-rays, which typically do not require prior authorization. It also encompasses basic restorative procedures, such as fillings, root canals, crowns, and dentures.
Coverage applies to all necessary extractions, including third molars (wisdom teeth). For individuals under age 21, coverage is more comprehensive due to the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. For adults aged 21 and older, coverage focuses exclusively on services deemed medically necessary to treat a condition or prevent a serious health issue.
Establishing Medical Necessity for Removal
The decision to cover wisdom teeth removal hinges entirely on establishing medical necessity. This standard mandates coverage for care necessary to prevent, diagnose, correct, or cure conditions that may cause acute suffering, endanger life, or interfere with a person’s capacity for normal activity. Medicaid generally does not cover the prophylactic removal of third molars that are asymptomatic, meaning they are not causing active problems.
To meet the medically necessary standard, a provider must document specific clinical pathology associated with the wisdom tooth. Qualifying conditions for removal include:
- Documented evidence of pericoronitis (infection of the gum tissue surrounding a partially erupted tooth).
- Teeth with non-restorable caries, internal or external resorption.
- Pathology such as cysts or tumors associated with the tooth.
- Damage caused by the impacted tooth to the adjacent second molar.
- Extraction required before a major medical procedure, such as an organ transplant or radiation therapy.
Navigating the Prior Authorization Process
Wisdom teeth removal is considered a surgical extraction, which almost always requires a mandatory administrative step called Prior Authorization (PA) or pre-approval before the procedure can be performed. The patient’s dental provider or oral surgeon must submit a formal request to the Managed Care Organization (MCO) or the Fee-for-Service administrator. This request serves as the formal justification for the procedure, linking the patient’s clinical symptoms to the established criteria for medical necessity.
The submission must include comprehensive supporting documentation, which typically consists of panoramic or periapical X-rays, detailed clinical notes from the examination, and a proposed treatment plan. The clinical notes are particularly important, as they must explicitly state the diagnosis and explain how the extraction meets the medical necessity standard, such as documenting recurrent infections or radiographic evidence of impaction-related pathology. Requests are submitted electronically or via paper forms to the state’s processing center. While providers are instructed to submit the request before service, the timeline for approval or denial can vary, and the patient relies on their provider to communicate the final determination from Medicaid.