The diagnosis of “root canal treatment” triggers double the stress for many patients: concern for the tooth and concern for the wallet. While we take care of the former medically, we want to shed light here on the often opaque jungle of cost coverage.
The answer to the question “Does the insurance pay for it?” is, as so often in medicine: “It depends.”
The principle of Statutory Health Insurance (GKV)
Statutory insured patients are entitled to treatment that is “sufficient, appropriate, and economical” (SGB V § 12). This means: the insurance pays for the preservation of a tooth, but only under strictly defined conditions.
The basic requirement: The tooth must be classified as worth preserving and the treatment must have a good prognosis. If the tooth is already too heavily damaged or the root is extremely curved, the insurance often refuses to cover the costs and instead only pays for the removal (extraction) of the tooth.
Special regulations for molars
The guidelines are particularly strict for the large molars in the back. Here, the GKV covers the costs for root canal treatment only if at least one of the following three points is met:
- Preservation of a closed row of teeth: The tooth is in an unbroken row up to the center. If it were missing, a gap would be created.
- Avoidance of a free-end situation: If the tooth were removed, there would be no tooth behind it (the row of teeth would “end freely”). This would make later tooth replacement significantly more difficult and expensive.
- Preservation of existing dental restorations: The affected tooth already supports a crown or bridge or serves as an anchor for a prosthesis that would become unusable if the tooth were lost.
Do none of these points apply? Then the GKV’s service catalog unfortunately provides for the removal of the tooth. Important: You can still decide in favor of tooth preservation! In this case, you bear the costs of the entire treatment as a private service.
Why do co-payments (“additional cost agreements”) arise?
Even if the insurance fundamentally says “yes” to the treatment, you often receive a treatment and cost plan for private co-payments. Why is that?
The insurance benefit covers basic care (X-rays, simple preparation, simple filling). However, modern endodontics offers technologies that can increase the chances of success from approx. 60% (basic) to up to 95% (high-end). These procedures are simply not included in the insurance catalog or are not reimbursed.
These include the “Big Four” of tooth preservation:
- Surgical microscope: You can only treat what you can see. The microscope makes hair-thin canals visible that would otherwise be overlooked. (Private service)
- Electrometry (length measurement): Instead of just taking X-rays, we measure the root length electronically. This is more precise and saves radiation exposure. (Private service)
- Chemical irrigation (ultrasound/laser): Bacteria reside in microscopic niches. Activated irrigation solutions reach these areas better than any file. (Private service)
- Thermoplastic filling: Instead of cold points, warm, liquid material is introduced, which also tightly seals lateral canals. (Private service)
Privately insured and supplementary insurance
- Privately insured (PKV): As a rule, the costs for modern procedures (according to the GOZ fee schedule) are reimbursed. However, check your tariff for any restrictions or deductibles.
- Supplementary dental insurance: Good tariffs often cover the out-of-pocket portion that the GKV does not pay (e.g., for the microscope). Important: The insurance must have been taken out before the diagnosis was established (“you cannot insure burning houses”).
Our advice: Transparency before treatment
Do not be surprised by cost plans. We create a detailed breakdown (treatment and cost plan) before every procedure. Ask us actively: “What is covered by insurance, what is private, and what specific benefit does the additional service have for my tooth?”
In the end, preserving your own tooth is almost always the better – and in the long term often even cheaper – solution than a gap or an implant.