Dental services for the majority are not covered by Medicare. Items and services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are not covered. These structures are defined as those directly supporting the teeth meaning the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process.
The hospitalization or nonhospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure.
When an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty. For example, the extraction of an impacted tooth is not covered. Similarly, an alveoplasty (the surgical improvement of the shape and condition of the alveolar process) and a frenectomy are excluded from coverage when either of these procedures is performed in conjunction with an excluded service, such as the preparation of the mouth for dentures.
Similarly, the removal of the torus palatinus (a bony protuberance of the hard palate) could be a covered service. However, with rare exception, this surgery is performed in conjunction with an excluded service, as the preparation of the mouth for dentures. Under such circumstances, reimbursement is not made for this purpose.
Payment may be made for other certain services of a dentist. The extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease is covered. This is an exception to the requirement, that to be covered, a noncovered procedure or service performed by a dentist and must be an incident to and an integral part of a covered procedure or service performed by the dentist. Ordinarily, the dentist extracts the patient's teeth, but another physician, e.g., a radiologist, administers the radiation treatments.
Here are some examples of possible coverage situations.
- Example 1 - The reconstruction of a ridge performed primarily to prepare the mouth for dentures is a noncovered procedure. However, when the reconstruction of a ridge is performed as a result of and at the same time as the surgical removal of a tumor (for other than dental purposes), the entirety of the surgical procedures is a covered service.
- Example 2 - Medicare makes payment for the wiring of teeth when this is done in conjunction with the reduction of a jaw fracture. 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 covered. Thus, an x-ray taken in conjunction 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 conjunction with the care or treatment of teeth or the periodontium is not covered.
Another exception is, an oral or dental examination performed on an inpatient basis as part of comprehensive workup prior to renal transplant surgery or performed in a RHC/FQHC prior to a heart valve replacement
Dental splints used to treat a dental condition are excluded from coverage under 1862(a) (12) of the Act. On the other hand, if the treatment is determined to be a covered medical condition (i.e., dislocated upper/lower jaw joints), then the splint maybe covered.
Whether services such 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 conjunction with the care or treatment of teeth or the periodontium is not covered.
Treatment of Temporomandibular Joint (TMJ) Syndrome
There are a wide variety of conditions that can be characterized as TMJ, and an equally wide variety of methods for treating these conditions. Many of the procedures fall within the Medicare program's statutory exclusion that prohibits payment for items and services that have not been demonstrated to be reasonable and necessary for the diagnosis and treatment of illness or injury (§1862(a)(1) of the Act). Other services and appliances used to treat TMJ fall within the Medicare program's statutory exclusion at 1862(a) (12), which prohibits payment "for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth...." For these reasons, a diagnosis of TMJ on a claim is insufficient. The actual condition or symptom must be determined.
Noridian has a policy covering oral appliances for Obstructive Sleep Apnea (OSA) which is administered through the Durable Medicare Contract (DME). View the Oral Device Local Coverage Determination (LCD) on the JA or JD DME website.
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services Section 150.1 - Treatment of Temporomandibular Syndrome
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1 - Inpatient Hospital Services, Section 70 - Inpatient Services in Connection With Dental Services
Last Updated Sep 09, 2016