Medicare Dental Coverage
- What Medicare Covers
Under Section 1862(a)(12) of the Social Security Act and 42 CFR 411.15(i), Medicare doesn’t pay for items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth except for inpatient hospital services connected to dental procedures if the patient is hospitalized because of 1 of these:
- The patient’s underlying medical condition and clinical status require hospitalization in connection with providing these procedures
- The severity of the dental procedure requires hospitalization
Medicare payment can be made under Part A and Part B when dental services are inextricably linked to the clinical success of other Medicare-covered services.
Examples of dental services that are inextricably linked to, and substantially related and integral to the clinical success of, certain Medicare-covered services could include, but aren’t limited to:
- Dental or oral exams as part of a comprehensive workup prior to, and medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with, a Medicare-covered:
- Organ transplant, including hematopoietic stem cell and bone marrow transplant
- Cardiac valve replacement
- Dental ridge reconstruction done as a result of and at the same time as surgery to remove a tumor
- Services to stabilize or immobilize teeth related to reducing a jaw fracture
- Dental splints, only when used as part of covered treatment of a covered medical condition such as dislocated jaw joints
- Tooth extractions done to prepare the jaw for radiation treatment for cancer
Medicare payment can also be made under Part A and Part B for ancillary services and supplies incident to the covered dental services, like:
- Administering anesthesia
- Diagnostic x-rays
- Operating room use
- Other related procedures
- What Medicare Doesn’t Cover
Medicare doesn’t cover items and services for the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. Structures directly supporting the teeth are the periodontium, which includes:
- Dentogingival junction
- Periodontal membrane
- Alveolar bone (alveolar process and tooth sockets)
Non-covered items and services include, but aren’t limited to:
- Routine dental care (services for the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth)
- Items and services done primarily to prepare the mouth for dentures, including:
- Alveoplasty (surgical improvement of the shape and condition of the alveolar process)
- Dental ridge reconstruction
- Removing the torus palatinus (a bony growth on the roof of the mouth)
- Dental services related to other non-covered services
Note: Some Medicare Advantage (MA) plans may cover and pay for routine dental services as an added benefit. Patients can check with their MA plan to find out what dental services it covers.
- What Are Inextricably Linked Dental Services?
Some dental services are so integral to other medically necessary services that the clinical success of the service is dependent upon, or inextricably linked to, the dental services. We provide some examples above of situations where there would be an inextricable link between dental services and other Medicare-covered services.
For dental services to be inextricably linked to other Medicare-covered services, different providers (like a doctor and a dentist) must coordinate care to provide:
- Medicare-covered services to treat the primary illness
- Dental services that are integral to the clinical success of the primary medical service
Without care coordination, health care providers won’t have the information they need to decide whether a dental service is inextricably linked to a Medicare-covered service. If the health care providers don’t coordinate care, Medicare won’t cover and pay for dental services. Examples of care coordination may include a referral or exchange of information between a medical doctor and a dentist.
You must document coordination in the medical record. Learn more about collaborating with other providers, including what to document.
- Does Medicare Pay for Multiple Dental Visits?
We pay for multiple visits if it’s clinically necessary for you to provide dental services that are inextricably linked to other Medicare-covered services in more than 1 visit. For example, Medicare may pay for multiple visits for dental services to eliminate a patient’s dental infection before an organ transplant.
- Who Can Provide Dental Services?
Medicare covers dental services provided by:
- Physicians, including a dentist or dental surgeon
- Non-physician practitioner
- Auxiliary personnel, like a dental technician, dental hygienist, dental therapist, or registered nurse, when:
- They’re directly supervised by a doctor or dentist
- The services meet the requirements for incident to services
- Who Can Bill for Covered Dental Services?
You must be a Medicare-enrolled provider to bill and get paid for providing Medicare-covered dental services.
If you’re not a Medicare-enrolled provider, visit Medicare Provider Enrollment to learn how to enroll. Or, you can provide services incident to services of a Medicare-enrolled physician or other practitioner. We’ll pay the Medicare-enrolled practitioner who bills for these services. These services must meet:
- The requirements for incident to services
- The appropriate level of supervision
- State law and scope of practice in the state where you provide the service
- How Do I Submit a Claim?
Use the appropriate CDT or CPT codes for the services you provided. When you submit a claim for Medicare-covered dental services, you’re certifying that the dental service is inextricably linked to a Medicare-covered medical service.
If you’re submitting a Medicare claim for a denial so you can get paid by a third-party payer (like Medicaid), include the appropriate HCPCS modifiers to certify that you believe Medicare shouldn’t pay the claim.
- Additional Resources