What insurance will help cover jaw surgery (and reimburse me the most)?
- Karim Hachem
- Mar 1
- 11 min read
Let’s get real here: Jaw surgery, also known as orthognathic surgery, isn’t a casual decision or a casual expense. If you’re reading this, you’ve probably discovered just how steep the costs can get—sometimes well over $50,000, and in some cases approaching $100,000 (yikes!).
Not only that, but it’s a complicated procedure that mixes the worlds of both medical and dental care.
That said, many people absolutely need it, whether it’s to fix a major bite issue, help with obstructive sleep apnea, address TMJ disorders, or correct facial asymmetry that makes everyday life difficult (think chewing, swallowing, speaking, or even self-confidence).
I recently had double jaw surgery in 2024, and it absolutely changed my life – I am not exaggerating. I sleep, breathe, think, exercise, and live 10 times better than before. Aesthetically, it’s helped bring balance to my facial features, I now look the way I should’ve always looked had I not had extraction orthodontics at 7 years of age.
It is expensive, difficult, and a journey – but it is absolutely worth it if you need it.
But take a deep breath: while your insurance may make the financial side of this a living nightmare, as long as you’re strategic about which plan you pick and how you navigate the coverage details, you can score a major win.
Below, I’ll walk you through some insider pointers, a comprehensive checklist (so you don’t miss a step), and overall things you should watch out for—based on real-world experience as well as some illuminating research.
By the end, you’ll (hopefully) feel a little more confident about making that big leap.
Why Jaw Surgery Matters (And Why It’s So Pricey)
First, let’s talk about why people get jaw surgery in the first place. Sure, a straighter smile is awesome, but this is about more than looks:
Bite Function: Some folks can’t chew properly because their upper and lower jaws simply don’t match up. It can lead to tooth damage, difficulty eating, and pain in the jaw joints (i.e., TMJs).
Obstructive Sleep Apnea (OSA): If your airways are compromised due to how your jaws are positioned, orthognathic surgery can help expand or realign that space so you’re not constantly waking up at night. This is a huge one—sleep apnea goes beyond loud snoring and can severely affect your overall health (heart issues, daytime fatigue, so on).
Speech and Swallowing Problems: A misaligned bite can make certain words or sounds pretty tough to say, and it may also lead to swallowing difficulties.
Chronic Pain or Injuries: Malocclusion sometimes results in cheek-biting, lip-biting, or fracturing teeth.
Facial Disfigurement and Self-Confidence: Facial asymmetry can really impact confidence and mental well-being. There’s a big difference between “cosmetic only” and “genuinely needed to restore someone’s health or daily function.”
Then there’s the money side. Surgery costs vary widely depending on your location, the surgeon’s fees, facility costs, anesthesia, whether you need an overnight hospital stay, etc.
Once you start tallying up all the line items, the totals can be alarming. Hence, it’s critical to know how your insurance coverage works—and how to fight for that coverage if you’re initially denied.
Quick Myth-Buster: Medical Insurance vs. Dental Insurance
Yes, jaw surgery is typically covered under your medical plan, not your dental. That means if you’re calling up your dental insurer and asking about “orthognathic surgery,” expect them to say, “No, that’s not us.” Dental insurance might, however, help with anything strictly under “dental services” which you may need as part of an interdisciplinary treatment plan, like orthodontics, periodontal care, tooth extractions, or prosthodontics (crowns, implants, etc).
The Basic Insurance Landscape
Before we dive into the nitty-gritty, here’s a broad overview of the usual suspects:
PPO (Preferred Provider Organization) Plans: Generally your best bet if you want to see a specific (potentially out-of-network) surgeon. If you’re absolutely set on using a well-known surgeon who isn’t in your network, a PPO tends to give you the best chance at partial coverage—though out-of-network coverage is usually less than in-network.
HMO (Health Maintenance Organization) Plans: Tends to require you to use in-network providers. Out-of-network services can be extremely limited unless you get a rare “Authorized Referral.”
EPO (Exclusive Provider Organization) Plans: Similar to HMOs—no coverage out of network except in emergencies, though occasionally you can get referrals authorized.
Anthem, Aetna, and Blue Cross/Blue Shield: Often more cooperative on jaw surgery claims—if the plan doesn’t explicitly exclude orthognathic surgery.
United Healthcare: We’ve seen more denials on jaw surgery, especially if you’re not dealing with a known congenital anomaly or moderate-to-severe sleep apnea.
Kaiser: Coverage can be fabulous if you stay in-network, with many people paying no more than a few hundred dollars for their surgery, but if you want to go out-of-network for a specialized surgeon, that’s muchmtrickier and we’d have a “strong avoid” indicator on this carrier if so.
No matter which you choose, always confirm that jaw surgery isn’t outright excluded.
Just because a plan covers “major medical procedures” doesn’t necessarily mean it’ll cover orthognathic surgery. Some policies specifically exclude it for specific etiologies (or specific causes, like United Healthcare oftentimes limiting it to people with moderate-to-severe sleep apnea only and no other reason).
Rarely, but a possibility no-less – a plan may exclude jaw surgery entirely. Read your contract carefully – do not skim the agreement.
A Deeper Look at Coverage and Medical Necessity
“Medical necessity” is the holy grail phrase. Insurers will generally approve your claim (or at least consider it) if they see jaw surgery as necessary to correct a legitimate health or functional problem. How do you prove that?
Remember this:
“Medical Necessity” is a legal term, and it is defined as such in your contract. It is not your definition, nor your doctor’s, nor anyone elses that matters for insurance coverage. Only your insurer’s definition matters, contractually and financially speaking – so you need to make sure that your case meets their definition of this term to ensure that your prior authorization is not denied.
Oftentimes this definition will be met by way of:
Documentation of your severe bite issue, speech pathology evaluations if you have speech difficulties, or official sleep study if you suspect obstructive sleep apnea.
Imaging (X-rays, CBCT scans) showing that your jaws are misaligned in ways that cause functional impairment.
Your surgeon’s “Letter of Medical Necessity,” detailing exactly how your health is impacted and why lesser treatments (like braces alone, CPAP for mild sleep apnea, or other less invasive surgeries) won’t necessarily do the trick without supporting evidence, but clinical notes from your surgeons office and their recommendation for surgery is certainly helpful.
Obstructive Sleep Apnea
Speaking of OSA: if it’s mild, some insurers might put up a fight—especially if you haven’t tried CPAP or an oral appliance first (this is what is known as “step therapy” – as in the insurer telling you to do/try “this” and “this” and “this” first, before we approve surgery).
But if your sleep apnea is moderate or severe, or you’ve failed other treatments, jaw surgery can be a powerful fix, and many plans (including Aetna, Anthem, BCBS) will cover it. But read the policy carefully; certain carriers have narrower guidelines or specific “step therapy” requirements.
Your Out-of-Pocket Max Matters
Look, if the surgery is going to cost upward of $50,000 (or more in many cases, close to $90,000), you’ll likely reach your plan’s out-of-pocket maximum (OOP max). Once you hit that OOP max for the year, the insurer generally pays 100% for additional covered expenses. This means:
A lower OOP max can be huge. Sometimes a plan with higher monthly premiums but a much lower OOP max is the better deal if you know you’ll be getting a big-ticket surgery.
The flip side: if for example you choose a plan with a $15,000 OOP max, you’ll be paying $15,000 out of pocket before insurance covers everything else (up to the allowable amount!)
Anything above the allowable amount is completely on you and is not included in any of their reimbursement calculations -- read the WARNING section below for more info about this. We'll also write a separate topic about this entirely in the future.
WARNING: It is very important to note that out-of-network reimbursements do not work in the way you think they do.
Most people believe that going out-of-network simply means they’re subjected to higher deductibles, out-of-pocket maximums, and higher coinsurances.
Yes, while this is true, the key thing to note is that out-of-network insurance RARELY uses your billed amount for surgery (what you paid your surgeon) as it’s basis for it’s reimbursement calculations -- read that again and don't move on until this settles in.
Instead, they will use an “allowable amount”, which is a figure they derive by using Medicare’s fee schedule or other data sources.
No matter how they derive the figure (which again, this is defined in your contract), it will be drastically lower than what you actually paid your surgeon.
This means that if you pay or example $65,000 for a top-tier jaw surgeon, insurance may only value that procedure at $8,000. The $8,000 in this example then becomes the basis of their deductible and coinsurance calucations.
This means, very often believe it or not, people will get reimbursed either $0 (entire amount applied to deductible) or a couple of thousand dollars on a procedure they paid tens of thousands of dollars on.
We deal with this all the time, we can help get you a “gap exception”, which means convincing your insurance carrier to utilize billed amounts (what you paid) and use your in-network benefits (lower coinsurance, lower deductible, lower out-of-pocket maximum) yielding you a significantly higher reimbursement.
We are very often able to get you 80% or more of your surgical costs reimbursed by doing this.
Hidden Landmines: Exclusions, Limitations & Fine Print
In addition to the big one above:
This is where many people trip up. You might see a quick summary listing your deductible, copays, etc., and think, “Cool, I’m covered!” But hidden deeper in the plan’s official Evidence of Coverage (EOC) might be a sentence saying something like, “Orthognathic surgery is excluded unless...XYZ .”
If that’s your plan, unless you meet that limited coverage criteria, you will not be covered—even if your situation is considered medically necessary.
So:
Dig Up the EOC (Evidence of Coverage). It might also be called the Booklet-Certificate, Benefits Booklet, Certificate of Coverage, or Plan Document. This is different from the Summary Plan Description.
Scan for “Exclusions” or “Orthognathic Surgery.” If you see an entire section that says “No coverage for jaw surgery except in XYZ,” take that seriously.
Look for Plan Year Benefit Maximums: Some marketplace plans impose annual caps on certain procedures. Orthognathic surgery can blow through that quickly if the limit is too low.
Understand the difference between in-network and out-of-network reimbursement modalities – we’ve explained this briefly in the WARNING section above. This part is important!
So Which Carriers Do I Recommend?
Anthem and Aetna PPO plans: We’ve seen a lot of success stories here—again, provided your EOC doesn’t exclude jaw surgery entirely.
Regional Blue Cross/Blue Shield: Typically a decent choice if they offer a plan that doesn’t list jaw surgery as a no-go.
Try to steer clear of United Healthcare if you have better options, especially for out-of-network or mild OSA. They’re known for restricting coverage and denying jaw surgery authorizations 80% of the time or greater (look at the study we’ve referenced and the chart below)
Kaiser can work if you don’t mind using Kaiser surgeons. If you want your own top specialist outside Kaiser’s network, that’s an uphill battle.
HMOs/EPOs: The coverage might be there, but you’ll have far less freedom if your surgeon is out of network. Not impossible, but more challenging.
Even if you’re stuck with one of the “tougher” carriers, appeals are certainly possible. Just be prepared to compile a thorough case showing your medical necessity.
The Ultimate Checklist
It’s Medical, Not Dental
Orthognathic (jaw) surgery goes through your medical insurance.
Dental insurance might chip in for orthodontic braces, periodontal treatments, or other “dental” items, but not the actual jaw surgery.
Go for PPO Plans to Maximize Surgeon Choice
If you have your heart set on an out-of-network surgical expert, a PPO is your safest route to at least partial coverage.
HMOs/EPOs might let you step out-of-network with an “Authorized Referral,” but it’s far from guaranteed.
Check for “Orthognathic Surgery Exclusions and Limitations”
Don’t rely on the summary docs. Crack open the 80+ page EOC to see exactly what’s written about jaw surgery.
Balance Monthly Premium vs. Out-of-Pocket Max
You will likely hit your OOP max with jaw surgery, so a lower cap can save you a bundle (even if premiums are a bit higher).
Prefer Anthem or Aetna
From experience (and patient anecdotes), these carriers often show more favorable outcomes, especially under a PPO.
Also consider your local Blue Cross/Blue Shield.
Be Wary of UHC and Possibly Kaiser
UHC might limit coverage to specific congenital anomalies or serious obstructive sleep apnea.
Kaiser typically works for in-network surgeons only.
Mind Pre-existing Condition Rules & Waiting Periods
The ACA mostly banned denials based on pre-existing conditions, but watch out for older or state-specific plans that might have special rules or waiting periods.
Get the EOC (a.k.a. Your Real Contract)
This is your insurance bible. If you can’t locate it online, call your insurer and demand a copy. It’s your legal right to have it.
Out-of-Network Surgical Centers
Even if your plan allows out-of-network surgeons, check if out-of-network facilities are covered. Some policies exclude coverage for ambulatory centers that aren’t in-network, which can be a major snag.
Keep an Eye on Plan Year Benefit Maximums
If your plan has them, see if they’re high enough—or at least confirm if your procedure is included in that coverage limit.
Appeals: What If You Get Denied Anyway?
Don’t panic if you receive a denial letter. Insurance denials for jaw surgery are more common than they should be, often for small technicalities (like requiring a speech pathologist’s letter, or a mandatory sleep study for OSA). If you’re denied:
Read the Denial Letter Thoroughly: They’ll spell out why you were denied. “Lack of medical necessity,” “excluded service,” “incomplete documentation,” etc.
Gather Evidence: Additional letters from your oral surgeon, orthodontist, or medical doctors; functional measurements; sleep study results; CT scans, cephalometric X-rays and analysis showing the severity of your jaw discrepancy.
Appeal It: Submit a formal appeal with all your new documentation, addressing their stated denial reasons directly.
Persist: Sometimes you’ll need multiple appeal stages, and you might even need an external review. If it’s truly medically necessary, don’t quit, don’t give up.
A 2020 study in the Journal of Oral and Maxillofacial Surgery showed that major insurers often have flawed or inconsistent guidelines for orthognathic surgery. In other words, you’re not alone if you find your insurer is being unreasonably stubborn.
Final Thoughts
Jaw surgery is one of those life-changing procedures that can boost not just your smile, but your entire well-being—from better sleep and pain relief to a significant confidence boost. But it can also be a minefield for insurance coverage if you’re not careful.
I hope the above tips give you a clearer path to picking the right plan—or at least knowing how to handle whatever coverage drama comes your way.
Remember: check your Evidence of Coverage, gather the best medical necessity documentation you can, and don’t assume a denial is the last word.
In fact, think of denials like we think of denials – a denial of a prior authorization or claim is really just a “delayed yes or approval”. A denial is the start of a conversation.
If you have to push through appeals, do it. The payoff can be huge—literally thousands upon thousands of dollars saved, and a better quality of life once your jaws are where they’re meant to be.
Wishing you smooth coverage, solid approvals, and a great outcome on your jaw surgery journey!
We know this is a lot to remember, and that this entire process can be daunting, complicated, and time-consuming – that’s why we are around.
Reach out to us for a free consultation on your case, we love winning and getting people approved with maximal reimbursement for this life changing surgery
We also don’t take no for answer.
A denied insurance prior authorization or claim is where we usually start.
Sources:
Schneider SA, Gateno J, Coppelson KB, English JD, Xia JJ. “Validity of Medical Insurance Guidelines for Orthognathic Surgery.” J Oral Maxillofac Surg. 2021;79(3):672–684. (PMC7925386)
Various Evidence of Coverage Documents (Aetna, Anthem/Blue Cross, Cigna, Humana, UnitedHealthcare, Kaiser)
American Association of Oral and Maxillofacial Surgeons (AAOMS) statements on Orthognathic Surgery
Disclaimer: This blog post is for informational purposes only and shouldn’t be taken as medical, legal, or financial advice. Always consult with qualified healthcare providers and insurance experts for guidance tailored to your specific policy and medical circumstances.