Dental Services

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(7) states Medicare will not cover any services or procedures associated with routine physical checkups.

CMS Internet-Only Manual, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §10.3 Certification for Hospital Admissions for Dental Services

CMS Internet-Only Manual, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, §70 Physician Defined and §70.2 Dentists

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 1, §30 Drugs and Biologicals and §70 Inpatient Services in Connection With Dental Services

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §120C Dentures and §150 Dental Services

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 16, §140 Dental Services Exclusion

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §260.6 Dental Examination Prior to Kidey Transplantation

Dental services are excluded from coverage in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth, except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures. Structures directly supporting the teeth means, the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process.

In an outpatient setting when an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty. An alveoloplasty and a frenectomy are excluded from coverage when either of these procedures is performed in connection with an excluded service: e.g. the non-covered extraction or the preparation of the mouth for dentures.

NON-COVERED SERVICES

(The only exception are for inpatient services: "except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures." )

• The extraction of an impacted tooth
• An alveoloplasty, (the surgical improvement of the shape and condition of the alveolar process), when performed for the preparation of the mouth for dentures
• Frenectomy when performed for the preparation of the mouth for dentures
• Extractions that are due to decay or periodontal disease
• Extractions done for the purpose of obtaining dentures
• Services related to chronic dental disease (i.e. gingivectomy)
• Removal of a benign growth or radicular cyst, in the mouth, or from structures directly supporting the teeth means the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process)
• Insertion of metallic implants used for enhancement of the structure of the jaws in order to support dentures or prosthesis
• Excision of torus mandibularis or excision of a maxillary torus palatinus is usually performed to accommodate a denture. The removal of the torus palatinus (a bony protuberance of the hard palate) and torus mandibularis could be a covered service. However, with rare exception, this surgery is performed in connection with an excluded service; i.e., the preparation of the mouth for dentures. Under such circumstances, reimbursement is not made for this purpose.

COVERED SERVICES:

• Surgery related to the jaw or any structure connected to the jaw including structures of the facial area below the eyes, for example (mandible, teeth, gums, tongue, palate, salivary glands, sinuses, etc.)
• Wiring of the teeth when performed in connection with the reduction of a jaw fracture
• Reduction of any fracture of the jaw or any facial bone, including dental splints or other appliances, if used for this purpose
• Reconstruction of a ridge if performed as a result of and at the same time as the surgical removal of a tumor (the total surgical procedure is covered)
• Removal of a torus palatinus (a bony protuberance of the hard palate) may be covered, if the procedure is not performed to prepare the mouth for dentures
• Extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease
• Insertion of metallic implants if the implants are used to assist in or enhance the retention of a dental prosthetic as a result of a covered service

The extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease is also covered. This is an exception to the requirement that to be covered, a non-covered procedure or service performed by a dentist must be an incident to and integral part of a covered procedure or service performed by the dentist. Whether such services as the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is itself covered. Thus, an x-ray taken in connection with the reduction of a fracture of the jaw or facial bone is covered. However, a single x-ray or x-ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered.

A dentist qualifies as a physician if, he/she is a doctor of dental surgery or dental medicine, and is legally authorized to practice dentistry in the state in which he/she performs such function, and who is acting within the scope of his/her license when he/she performs such functions. Such services include any otherwise covered service that may legally and alternatively be performed by doctors of medicine, osteopathy and dentistry; e.g., dental examinations to detect infections prior to certain surgical procedures, treatment of oral infections and interpretations of diagnostic x-ray examinations in connection with covered services. Payment for the services of dentists in an outpatient setting is limited to those procedures which are not primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting the teeth. The coverage of any given dental service is not affected by the professional designation of the physician rendering the service; i.e., an excluded dental service remains excluded and a covered dental service is still covered whether furnished by a dentist or a doctor of medicine or osteopathy.

Dental Examination Prior to Kidney Transplantation

An oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery is a covered service. This is because the purpose of the examination is not for the care of the teeth or structures directly supporting the teeth. Rather, the examination is for the identification, prior to a complex surgical procedure, of existing medical problems where the increased possibility of infection would not only reduce the chances for successful surgery but would also expose the patient to additional risks in undergoing such surgery.

N/A

N/A

Documentation Requirements

1. Documentation supporting the medical necessity, such as ICD-10 codes, including the need for the surgery in an inpatient setting, must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.
2. Where the dental procedure is not the primary procedure performed, documentation of the primary procedure must be included in the patient’s medical records.
3. Documentation must be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B MAC upon request.

Utilization Guidelines

If a non-covered service is performed as the primary procedure in conjunction with a covered procedure or service, regardless of the complexity, the total service is excluded from coverage.

Anesthesia services, provided by the surgeon performing the surgery, is considered bundled into the payment for the surgical procedure. Since the payment is bundled, the physician is precluded from billing the beneficiary for this service.

Where a patient is hospitalized solely for less than major noncovered dental treatment, both the professional services of the dentist and the inpatient hospital services are not covered. "except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures."

Items and services in connection with an excluded dental service (the care, treatment, filling, removal or replacement of teeth, or structures directly supporting the teeth) are not covered. (i.e. anesthesia services, lab, x-ray services).

Amalgamation of national policy

• Dental