Dental

Dental Services

Dental services, minus a few exceptions, are not a Medicare covered benefit per regulation [(SSA 1862(a)(12) and 42 CFR § 411.15(i)]. These include services in connection with teeth and structures directly supporting the teeth, meaning the periodontium; which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar bone (alveolar process and tooth sockets). Example non-covered dental services include but are not limited to: dental screening services, dental prophylaxis, treatment of simple dental caries, routine tooth extractions, dental prosthetics, splints, dentures, oral appliances, and restorative treatments such as crowns and implants. When an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty. The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure.

For dates of service January 1, 2023, and after, Medicare may pay for additional dental services that are "inextricably linked" and substantially related and integral to the clinical success of, a certain covered primary medical service. Such services include, but are not limited to:

  • Dental or oral examination performed 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 these Medicare covered services:
    • organ transplant
    • cardiac valve replacement
    • valvuloplasty procedure
  • The reconstruction of a dental ridge performed because of and at the same time as the surgical removal of a tumor
  • The stabilization or immobilization of teeth in connection with the reduction of a jaw fracture, and dental splints only when used in conjunction with covered treatment of a covered medical condition such as dislocated jaw joints
  • The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease
  • Ancillary services and supplies furnished incident to covered dental services including, but not limited to the administration of anesthesia, diagnostic x-rays, use of operating room, and other related procedures.

For dates of service January 1, 2024, and after, CMS included additional circumstances in the treatment of cancer for which dental services may be considered "inextricably linked", including:

  • Dental or oral examination performed 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: Chemotherapy services, Chimeric Antigen Receptor T- (CAR-T) Cell therapy, and the administration of high-dose bone modifying agents (antiresorptive therapy) when used to treat cancer
  • Dental or oral examination performed as part of a comprehensive workup prior to, medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with, and medically necessary diagnostic and treatment services to address dental or oral complications after, the Medicare-covered treatment of head and neck cancer using radiation, chemotherapy, surgery, or any combination of these.

Inextricably Linked Definition

For a dental service to be considered "inextricably linked" to a covered primary medical procedure or service:

  • Evidence-based literature and/or clinical standard of care must be demonstrated such that the provision of these dental services prior to or contemporaneously with a covered primary medical procedure or service if not performed would result in a material difference in terms of clinical outcomes and success of the medical procedure or service.
  • Care coordination (e.g. between the doctor and the dentist) must have occurred with documentation to support (e.g. referral or exchange of information). MLN-Collaborative Patient Care is a Provider Partnership

Additional Details:

  • Inextricably linked dental services:
    • May be covered by Medicare Part A or B
    • May be covered over multiple visits
    • May occur in the inpatient or outpatient setting
    • May be performed by a physician (including a dentist or dental surgeon), non-physician practitioner, or auxiliary personnel (e.g. dental hygienist, dental technician, registered nurse) meeting state scope of practice requirements working in an incident to relationship as per 42 CFR § 410.26
    • Must be billed by a Medicare enrolled provider, either the dental provider or Medicare enrolled physician or non-physician practitioner with a dental provider working under an incident to relationship

Claim Submission Requirements

To be eligible to bill and receive direct payment for professional services under the Medicare part B Physician Fee Schedule, enrollment in Medicare is required. To learn how to enroll as a Medicare provider, visit the provider enrollment page.

Information on enrolling and testing for 837D Dental claims refer to Electronic Data Interchange . Click on your state

Claims may be submitted using the dental (837D), institutional (837I) or professional (837P) claim forms, and Medicare will accept CDT© or CPT/HCPCs© codes when billed.

Medicare fee for service requires a minimum of one ICD-10 diagnosis code to be billed on any claim form seeking reimbursement for services. This diagnosis is not required to be the diagnosis for the covered primary medical service; it may be a diagnosis reflective of the dental treatment. Claims received on or after January 1, 2025, will reject if not submitted with a valid ICD-10 diagnosis.

Modifiers

Modifier KX is reported on a Medicare Part B claim to indicate:

  • A service or item is medically necessary and,
  • The provider has appropriate documentation in the medical record to support or justify medical necessity

Beginning on July 1, 2024, providers may also report modifier KX on claims for dental services to expedite a MAC's determination of inextricable linkage if:

  • A physician, including a dentist, is certain they possess information to support that the dental services are medically necessary and inextricably linked to a covered primary medical service in adherence to regulation; and,
  • Coordination of care between the medical and dental providers occurred and payment requirements have been met

Providers are encouraged (but not currently required) to include modifier KX on dental claims. However, claims received on or after July 1, 2025, will require the KX modifier (per line item) to indicate that a provider believes that the dental service performed is medically necessary, that the provider has included appropriate documentation in the medical record to support the inextricable link to a covered primary medical service, and that coordination of care between the medical and dental practitioners has occurred.

Beginning on January 1, 2025, MACs may deny dental claims that do not contain modifier KX as statutorily non-covered.

Advance Beneficiary Notice of Noncoverage

Modifier GY is reported on a Medicare claim to indicate:

  • An Item or service is statutorily excluded and does not meet the definition of any Medicare benefit

If a provider believes that Medicare will deny some or all the services or items because of medical necessity or an "inextricable link" may not be present, an Advance Beneficiary Notice of Noncoverage (ABN) should be issued in writing to the Medicare beneficiary. The ABN is optional when Medicare never covers a service, for example a benefit category denial, but should be used if Medicare does cover the service for some diagnoses, but the provider believes it will not be covered for a particular situation. You may submit statutorily excluded services as non-covered line items on a claim with other covered dental services (like dental services inextricably linked to the clinical success of other Medicare-covered procedures or services) by adding the GY modifier to that claim line.

For a provider submitting a Medicare claim to produce a denial so that Medicaid or another third-party payer can make primary payment, they may submit a claim with the appropriate HCPCS© modifier up front so that Medicare does not pay the claim. For example, the GY modifier may be used to indicate that an item or service is statutorily excluded, or the service does not meet the definition of a Medicare benefit and that Medicare should not pay for the service.

To learn more about the ABN process visit our website.

Note: all Medicare claims may be subject to normal review in accordance with Medicare rules and regulations. Should the dental services provided fail to demonstrate inextricable linkage and thus fall under the statutory exclusion of dental services, the claim may be denied as a benefit category denial subject to beneficiary liability.

For more information visit Medical dental coverage page.

Hospital Services With Dental Services

The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure. Should the dental services provided fail to demonstrate inextricable linkage and thus fall under the Medicare Dental Exclusion, the claim may be denied as a benefit category denial subject to beneficiary liability.

Dental Splints

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.

Temporomandibular Joint (TMJ) Syndrome Treatment

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.

Oral Devices

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.

References

Last Updated Nov 12 , 2024