Does dental insurance cover wisdom tooth removal?
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A typical adult has 32 teeth,1 but the last four to develop often feel like an unwelcomed addition to the party. These last teeth, known as your third molars or wisdom teeth, once served a purpose for an early human's diet. But nowadays, they often don't grow in properly and are considered unnecessary.2 Why? Wisdom teeth can become impacted, meaning they don’t have enough room to grow in properly, which can lead to a whole host of dental issues3 like:
Gum disease
Jaw pain
Cysts
Infections
Crowding or damage to nearby teeth
Dealing with problematic wisdom teeth
Many people get their wisdom teeth removed by a dentist or oral surgeon. Some do it proactively to avoid future problems, while others wait to see how their wisdom teeth grow in.
According to conventional wisdom – and Guardian research – the types of preventive care services covered by dental insurance can help people save on important care in the long run. That said, wisdom teeth removal tends to be more involved, so it falls under a different insurance classification than basic preventive care like oral exams and cleanings.
For one thing, it's a complex procedure that often requires more than just a local anesthetic for pain control. In many cases, dentists or oral surgeons remove your wisdom teeth using a form of partial sedation such as laughing gas or IV sedation. General anesthesia, where you're fully unconscious, is less commonly needed for wisdom teeth removal.4
The cost of wisdom teeth removal also depends on the complexity of the extraction, including other factors like your state of residence. In many cases, dental insurance can cover at least part of the cost of wisdom teeth removal. However, the specifics depend on factors like your dental insurance plan, your dental condition, and your location.
Is wisdom teeth removal covered by dental insurance?
Whether you have Guardian Dental Insurance or coverage from another provider, the answer is it depends – typically on whether you have a basic plan that just covers preventive care or a more comprehensive plan that covers oral surgeries.5
Many Guardian plans provide at least partial coverage for oral surgeries — including surgical removal of wisdom teeth — but it depends on the specific terms of your plan, which can vary based on your employer, location, or the coverage level you choose. Again, whether you have coverage from Guardian or another provider, factors to consider include:
The type of insurance plan
The type of plan you have — either a Dental PPO (Preferred Provider Organization) or Dental HMO (Health Maintenance Organization) — can make a difference in coverage. In general, Dental PPOs provide more freedom to see a wider network of dental clinics and specialists, like oral surgeons, compared to HMO plans. And while all PPO typically plans offer preventive care benefits, they may or may not cover "major" procedures like oral surgery. However, even if wisdom tooth removal isn't covered under your plan, you should be able to receive a network discount or reduced rate if you see a participating provider.
Medical necessity
Oral health is important to overall body health, so another issue is whether or not your wisdom teeth removal is medically necessary. As mentioned, some dentists recommend proactively removing wisdom teeth to avoid complications later in life. However, there's a better chance your dental insurance plan will cover wisdom teeth extraction when it’s deemed medically necessary.
But remember, there are no hard and fast rules here. In general, it's a good idea to check with your dentist or oral surgeon about what's covered by your specific insurance plan, and make sure you are following any preauthorization requirements.
Coverage levels, limits, and waiting periods
You also want to be mindful of issues like coverage levels, limits, and waiting periods. If you’ve already reached your annual maximum benefits under your dental plan, for example, then wisdom teeth removal wouldn’t be eligible for any coverage until your benefit limits reset, typically in the next plan year. (However, you may still be eligible for in-network discounts.)
Waiting periods may also be a factor, especially if you just started a new insurance plan. To discourage people from waiting until the last moment to get coverage, many plans don’t provide oral surgery benefits right away.
Age restrictions
Some dental insurance policies have age restrictions around wisdom teeth removal. In particular, a plan meant for children or young adults could provide different coverage for wisdom teeth removal than some adult plans. The medical necessity of wisdom teeth removal can also vary by age.
Plus, not everyone develops wisdom teeth at the same time, although the typical age range is between 17-25 for these third molars to emerge.6 Carefully review the coverage details of your dental insurance to see if age restrictions or any other limitations affect coverage for wisdom teeth.
How to use dental insurance to cover wisdom teeth extraction
If you don't want to pay the full cost of wisdom teeth extraction out of pocket, it helps to understand how the following factors can affect what you pay, assuming you have oral surgery benefits:
Using in-network providers
If you have a dental HMO plan, you can only get coverage from a network provider. With a PPO plan, if you visit an in-network provider, they will typically handle insurance claims on your behalf and should be able to provide a reasonably accurate estimate of your out-of-pocket costs for the procedure (barring any complications). Again, you'll also be getting preferred in-network rates that can help lower your cost.
Out-of-network providers
In many cases, if you use an out-of-network provider for oral surgery deemed medically necessary, then your dental insurance may tell you to first submit a claim to your health insurance provider (although, in some cases, the oral surgeon's office may do this for you).
Then, once your health insurance provider has reviewed and processed the oral surgery claim, you can submit their Explanation of Benefits (EOB) regarding the oral surgery claim to your dental insurer, who will assess if any remaining amounts qualify for coverage under your specific dental insurance plan.
HSAs or FSAs
If you qualify for a Health Savings Account (HSA), or if your employer offers Flexible Spending Accounts (FSAs), you may be able to use these accounts to help pay some of the costs of wisdom teeth removal without taking it out of your take-home pay or other savings.
Generally speaking, HSAs and FSAs provide tax savings because they are funded with pre-tax dollars, so you don't pay income tax on money that goes into the account. These funds are typically available to pay for health-related expenses like co-payments and deductibles that your medical or dental insurance does not cover – and wisdom teeth extraction is a health-related expense.7
How to check your Guardian dental benefits
You can check your plan details within the Guardian member portal to determine your specific benefits. You can also use the portal to find an in-network dentist and use our cost estimator to get a sense of what a procedure could cost.
But remember, don't wait until your teeth start hurting: Because more-involved procedures like wisdom teeth removal tend to have waiting periods, you should proactively sign up for dental benefits at work so you can have the coverage you require when you need it – whether it's for extractions or other dental procedures. If you no longer have dental coverage through work (or it isn’t offered), consider exploring individual and family coverage options.