What is the “missing tooth clause”?
The short answer
Some plans won't pay to replace a tooth that was already gone before your coverage started. It's the dental version of a “pre-existing condition” rule, and it can apply to bridges, implants, and partial dentures.
Not every plan has one
Some plans don't use this clause, and some cover replacing teeth lost before you joined. Check your plan's limitations section or ask member services directly.
Not the same thing: a tooth that never grew in
Some people are born without certain adult teeth. Dentists call these teeth congenitally missing. Some plans have a separate rule that doesn't pay for treatment to correct a condition you were born with, and that can include replacing a tooth that never formed.
The two are easy to mix up. If your plan doesn't have a missing tooth clause but a claim to replace a tooth was still denied, check whether the reason mentions a condition present from birth. That's a different rule, usually spotted by the dentist who reviews your X-rays and records.
Things that may help
- Prior coverage. Some plans shorten or drop the exclusion if you had dental coverage right before joining.
- Records of when the tooth was removed. If the tooth was taken out after your coverage began, your dental records show that.
- A predetermination. Ask your dentist to send the treatment plan to your insurer before starting, so you know whether the clause applies.
Questions to ask
- Does my plan have a missing tooth clause?
- Do your records show the date this tooth was removed?
- Can you send a predetermination before we start?