Crown lengthening is a surgical procedure that reshapes gum tissue and sometimes bone surrounding a tooth to expose more of the tooth’s structure. Whether a dental insurance plan covers this procedure is highly complex and variable, depending almost entirely on the specific reason the treatment is performed. The determination of coverage requires a careful review of the patient’s clinical needs and the insurance policy’s specific language regarding covered services. Patients must understand the procedure’s purpose and their plan’s administrative requirements.
Understanding Crown Lengthening Procedures
Crown lengthening is a precise periodontal procedure, typically performed by a periodontist, to modify the soft tissue and sometimes the underlying bone around one or more teeth. This modification involves the surgical removal of excess gum tissue and occasionally the reshaping of the alveolar bone to reveal more of the tooth’s surface. The procedure serves two distinct purposes: functional and aesthetic. Functional crown lengthening is performed to prepare a tooth for a restorative procedure, such as placing a new crown or filling, by ensuring enough tooth structure is available. Aesthetic crown lengthening is primarily done to improve the appearance of a “gummy smile,” where excess gum tissue makes the teeth appear short.
Factors Determining Coverage Eligibility
Insurance coverage for crown lengthening hinges on establishing a clear medical necessity, meaning the procedure is required to maintain or restore the health and function of the tooth. Coverage is typically approved when the procedure is a necessary precursor to another covered restorative treatment. This includes situations where a tooth has fractured or decay extends deeply below the visible gum margin, making it impossible to place a proper filling or crown. Another common justification is the violation of “biologic width,” the necessary minimum distance between the edge of a dental restoration and the underlying jaw bone; crown lengthening is required to re-establish this proper biological distance if preparation encroaches on this space. Conversely, crown lengthening performed solely to correct a gummy smile or enhance appearance is nearly always classified as a cosmetic procedure and is not covered by standard dental insurance plans.
The Pre-Authorization and Appeals Process
Securing coverage for crown lengthening requires the administrative step of obtaining a Pre-Treatment Estimate, also known as Pre-Authorization or Pre-Determination, before the procedure is scheduled. This estimate gives the patient and the dentist a clear understanding of what portion, if any, the insurance company will cover. The dental office must submit a comprehensive package to the insurer to support the claim of medical necessity.
This documentation typically includes recent periapical X-rays that show the extent of the decay or fracture and the relationship to the bone level. A detailed narrative report from the treating periodontist is also required, explicitly describing the diagnosis and explaining why the procedure is necessary for the long-term prognosis of the tooth, avoiding any language that suggests an aesthetic motivation. If the insurance carrier initially denies the claim, the next step is to file a formal appeal, which often involves submitting additional clinical evidence, such as intraoral photographs or an updated, more detailed narrative.
Financial Planning for Uncovered Costs
When insurance coverage is denied or only partially covers the procedure, patients must be prepared for the out-of-pocket expenses. The cost for crown lengthening can vary significantly based on the complexity, the number of teeth involved, and geographic location.
Patients have several options to manage these costs when insurance coverage is not available.
- In-house payment plans allow the total fee to be paid over a period of time, sometimes with low or no interest.
- Healthcare credit cards, such as CareCredit, provide a dedicated line of credit for medical and dental expenses.
- Dental savings plans offer discounted rates on procedures in exchange for a yearly membership fee.