Jaw surgery falls under medical insurance, not dental insurance. However, there is often orthodontic treatment associated with it, and that falls under the dental realm rather than medical. (See section on what insurers pay below).

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Insurance claims and approvals are for a specific surgeon, meaning a patient gets approved for jaw surgery with a specific surgeon rather than for jaw surgery generally. If the patient decides during the preparation process to switch surgeons, the insurance coverage process must be started over. This means you should decide on your treatment provider first (e.g. doing consults with various surgeons) before committing to one and having them submit a prior authorization claim to your insurer.

• The most common quantitative measure is AHI (which stands for “Apnea-Hypopnea Index”), and it counts the number of apneas (pauses in breathing) and hypopneas (partial blockages or reductions in airflow) that occur per hour of sleep.
• Another quantitative measure is RDI (“Respiratory Disturbance Index”), which captures not only apneas and hypopneas like AHI does, but also RERAs: events where there’s increased respiratory effort due to resistance, leading to arousal from sleep, but they don’t necessarily meet the criteria of apneas or hypopneas. The RDI number is usually higher than the AHI number, and if you choose to appeal a denial, it can be argued that RDI is a more accurate measure.

These include:

1. Imaging (like a CBCT scan) showing your recessed jaws causing a tiny airway. If you get this, make sure to stand up straight; people with recessed jaws can often adopt a “forward head posture” in order to compensate for a small airway, so you should avoid doing this to show how bad your airway is.
2. Patient complaints of poor sleep and symptoms caused by it. These can include:
   1. Fatigue
   2. Impaired memory
   3. Reduced cognitive function
   4. Mood disturbances
   5. Weakened Immune System
   6. Etc.

• CPAP, which stands for “Continuous Positive Airway Pressure.” It is a machine used to treat sleep apnea by delivering a continuous stream of air to keep the airways open during sleep, preventing pauses in breathing. It’s known by many medical professionals as the “gold standard” in treating obstructive sleep apnea, but many patients aren’t able to remain “compliant” in using it.
• Mandibular advancement devices (MADs) are oral appliances used to treat sleep apnea and snoring. They work by repositioning the lower jaw (mandible) forward, which helps keep the airway open during sleep. However, they can cause damage to the teeth and temporomandibular joints, and they do not fix any problems with nasal breathing.
• Soft tissue surgeries, which open up the airway by moving the soft tissues (rather than bones) out of the way. Note that many of these surgeries, while still endorsed by insurers, are falling out of favor with top sleep surgeons because they are often not effective. These surgeries include:
  • Uvulopalatopharyngoplasty (UPPP): Removal of excess tissue from the throat to widen the airway.
  • Tonsillectomy: Removal of enlarged tonsils that may be obstructing the airway.
  • Adenoidectomy: Removal of the adenoids if they are causing obstruction.
  • Genioglossus Advancement (GA): Repositioning of the tongue muscle attachment to advance the tongue forward, preventing it from collapsing backward.
  • Lingual Tonsillectomy: Removal of enlarged lingual tonsils at the base of the tongue if they contribute to airway obstruction.
  • Nasal Surgery: Such as septoplasty, turbinate reduction, or polyp removal, to address nasal obstructions that contribute to apnea.
  • Hyoid Suspension: Anchoring the hyoid bone (in the neck) to the thyroid cartilage to stabilize the region and prevent airway collapse.
• Inspire Therapy: Implantation of a device that stimulates the hypoglossal nerve, preventing airway collapse. As this is a newer treatment, insurers don’t typically recommend it by default as a “step” therapy.

Note that another surgery being increasingly recommended before jaw surgery is maxillary expansion, such as Kasey Li’s EASE procedure. These procedures widen the nasal passages, enabling better airflow.

If you don’t qualify with enough of a bite issue now, you might qualify later after you’ve had the pre-surgery orthodontic treatment, because this typically “decompensates” the bite such that it gets “worse” before surgery, which can bring you “over the line” of medical qualification. However, we’ve seen an insurance plan warn that you must get approval before undergoing pre-surgery treatment, but it’s not known whether this is enforced (and we’ve had a surgeon’s office recommend to start orthodontic treatment before submitting for insurance approval).

Diagnosis #3: Temporomandibular joint (TMJ) disorders

This is not the best issue to utilize for jaw surgery because most insurance companies claim that jaw surgery is “experimental/investigational” for TMJ disorders, which basically means there isn’t enough proof in medical studies that it is an effective treatment. If that’s the case, you can appeal and argue that there is enough proof and nothing else works in your case.

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Insurers sometimes have a flat-out exclusion listed for TMJ disorders, which will be listed in your Plan Document. This doesn’t mean that you can’t get treated if you have a TMJ disorder; it just means that the TMJ disorder isn’t enough to qualify you for treatment alone. You can still get treated for TMJ issues if the treatment also addresses a different problem that insurers will cover.

‍Diagnosis #4: Skeletal discrepancies

Like TMJ disorders, this is another difficult one to get covered because it’s vague, but it is possible. It’s commonly used as an adjunct to other diagnoses by surgeons when they file a claim to your insurer; some surgeons even map out the dimensions in a CT scan and show where you as a patient deviate from the norms.

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Insurers will usually define that your skeletal issues must be at least two standard deviations away from the norm. They aren’t usually specific on what that means, which leaves room for argument if you appeal (see section on appeals below).

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Note that cosmetic concerns with appearance will not be covered by insurers, and it’s best not to mention these in the claims and appeals.

Here are the various components of jaw surgery treatment, and whether the cost is paid by your insurer in the US (note that our claims here are for the majority of cases but you’ll need to confirm if the same rules apply to you):

1. Surgeon’s fee: medical insurance will cover, but you’ll pay a portion of the costs. If the surgeon is out-of-network, your insurer will only pay a small amount or nothing at all, depending on your out-of-network benefits.
2. ‍Additional surgery fees (anesthesia, operating room, etc.): medical insurance will cover, and you might pay a portion of the costs (although often the surgeon’s fee is large enough to exhaust your “deductable” anyway, so you might not pay any of this). Just ensure that you’re getting surgery at an in-network facility; usually out-of-network surgeons are able to perform the procedure at in-network facilities.‍
3. Overnight hospital stay: medical insurance will cover, and you might pay a portion of the costs (although often the surgeon’s fee is large enough to exhaust your “deductible” anyway, so you might not pay any of this). Ensure that it’s an in-network hospital. Note that if your insurer deems your procedure not medically necessary, the hospital stay could be tens of thousands of dollars (or more if you need to stay multiple nights), but some surgeons that handle cosmetic cases have rates of just a few thousand dollars that they arranged with the hospital.‍
4. Consultations: medical insurance will cover, and you’ll have a co-pay for a portion of that. Be careful to ensure that these consults are covered because the cost can be hundreds of dollars (and we’ve seen up to $1000). Some insurance plans (often HMOs) require a referral from a primary care provider for a specialist visit to be covered. Insurers will typically pay out much less for out-of-network consults than in-network consults. Insurance will not typically cover travel costs to these consults. Note that some surgeons are now offering virtual consults.‍
5. Orthodontic treatment before/after jaw surgery (including tooth extractions): medical insurance will not cover, as this falls into the “dental” realm. Keep in mind that dental insurance, even good dental insurance, won’t cover nearly as much of the cost as medical insurance does (especially if you’re an adult patient), and you might need to pay the entire bill for orthodontics. This can cost many thousands of dollars depending on your treatment plan.‍
6. Genioplasty (which is often done concurrently with jaw surgery): medical insurance will not cover, as this is typically considered cosmetic. One could argue that genioplasty is medically necessary because it opens up the airway more, but the evidence for this is hit-and-miss. We have heard of insurers covering this anecdotally, but wouldn’t recommend counting on it.‍
7. Rhinoplasty (which is occasionally done concurrently with jaw surgery): medical insurance will not cover, as this is typically considered cosmetic. Note that if you have a septoplasty (a non-cosmetic procedure in which a deviated septum is corrected to improve nasal breathing), that portion of the rhinoplasty can be covered.‍
8. Post-operative therapy, including physical therapy, speech therapy, or other rehabilitative services: medical insurance will cover if they’re prescribed by a physician and deemed medically necessary in your case, but there could be a limit on the number of covered sessions.‍
9. Home care/recovery supplies (mouthwashes, antibacterial gels, cooling facemasks, etc.): medical insurance will cover if they’re by-prescription, but they will typically not be covered when they’re over-the-counter (although you might be able to use a Health Savings Account or other benefits for them).‍
10. Tests/labs to ensure you’re ready for surgery: medical insurance will cover, as long as you get the tests at an in-network facility.