An overbite, known clinically as a malocclusion, is a condition where the upper front teeth vertically overlap the lower front teeth by an excessive amount. While a small overlap of one to two millimeters is considered normal, an overlap exceeding three or four millimeters is often classified as a deep bite and may require intervention. When the jaw misalignment is severe and cannot be corrected by orthodontics alone, the treatment may involve orthognathic surgery, which is a specialized procedure to reposition the jawbones. Securing insurance coverage for this type of surgery is rarely straightforward and depends almost entirely on the specific health impact of the jaw misalignment.
Medical Necessity Versus Cosmetic Care
Insurance coverage for overbite surgery hinges on a fundamental distinction: whether the procedure is considered medically necessary or purely cosmetic. Medical necessity requires concrete evidence that the jaw misalignment is causing a functional impairment that significantly affects a person’s health. This impairment goes far beyond the desire for an improved appearance and must be documented by healthcare professionals.
Insurers typically look for specific symptoms, such as severe difficulty chewing or swallowing, chronic jaw joint pain (Temporomandibular Joint Disorder, or TMJD), speech impediments, or compromised breathing, including obstructive sleep apnea. The misalignment must be the root cause of these health issues to qualify for coverage. A common benchmark some providers use is a minimum skeletal discrepancy, such as a horizontal or vertical jaw difference of five millimeters, which must be verified through diagnostic imaging.
If the surgery is primarily intended to improve the facial profile or the aesthetic alignment of the teeth, it will almost certainly be classified as cosmetic and excluded from coverage. The documentation provided by the surgeon and orthodontist must clearly establish that the skeletal imbalance is creating a measurable physical dysfunction that requires surgical correction. This functional focus is the primary hurdle in gaining approval for orthognathic procedures.
Dividing Costs Between Medical and Dental Policies
The total cost of overbite correction is often complex because it involves both medical and dental components that fall under separate insurance policies. The orthognathic surgery itself—the actual bone cutting, repositioning of the maxilla or mandible, hospital stay, and anesthesia—is billed under the patient’s major medical insurance. This is because the procedure addresses a skeletal or structural defect, making it a medical rather than a purely dental event.
In contrast, the orthodontic treatment required both before and after the surgery is typically covered, if at all, by the patient’s dental or orthodontic insurance plan. This includes the cost of braces, wires, and any post-surgical retainers, which prepare the teeth for their new jaw position. Dental policies often have annual spending caps or lifetime maximums, which can be quickly reached by the necessary pre-surgical orthodontics.
It is important to understand that approval for the medical portion of the surgery does not guarantee coverage for the dental portion. The patient must coordinate benefits between the two distinct plans, and it is common for the out-of-pocket costs for the orthodontic phase to be substantial, even if the medical surgery is covered.
The Pre-Authorization and Appeals Process
Before any procedure is scheduled, obtaining a pre-authorization from the medical insurer is a mandatory step. This process confirms whether the proposed surgery meets the plan’s criteria for medical necessity and is a covered benefit. The surgeon’s office and the orthodontist will collaborate to submit an extensive package of documents to the insurance company.
Required documentation typically includes detailed records such as cephalometric X-rays, CT scans, dental molds, and a comprehensive treatment plan outlining functional issues. A formal letter of medical necessity from the surgeon and orthodontist must accompany these records, specifically referencing the patient’s functional impairments. The insurance review process can take four to six weeks or longer, especially if the insurer requests additional information.
If the initial request for coverage is denied, patients have the right to file an internal appeal with the insurance company. This involves submitting further evidence, often including a more detailed narrative from the surgeon or a request for a peer-to-peer review between the treating surgeon and a physician employed by the insurer. Should the internal appeal fail, an external review by an independent third party may be requested.