Does Medicare Cover Dental Procedures?
Many of our members ask Does Medicare Cover Dental Procedures? Medicare coverage of dental services is very limited. Medicare does not cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. Medicare does not pay for dental plates or other dental devices. In general, you pay for 100% of dental services.
This has given rise to the popularity of discount dental plans.
Section 1862 (a)(12) of the Social Security Act states in partial that Medicare will not cover dental care, “where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” Structures directly supporting the teeth means the periodontium, which includes the gingivae, periodontal membrane, dentogingival junction, cementum of the teeth, and the alveolar bone (i.e. alveolar process and tooth sockets).
The dental exclusion was included as part of the initial Medicare program. The principle being that Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.
Medicare does cover these types of dental services:
Dental services that are an integral part of a covered procedure (e.g., reconstruction of the jaw following accidental injury).
Extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw.
Oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances. Such examination would be covered under Part A if performed by a dentist on the hospital’s staff or under Part B if performed by a physician. 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.
Hospital stays if needed for emergency or complicated dental procedures, even when the dental care itself is not covered. In these cases you should call your Part A contractor for more information.
Inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.
Surgical procedures for the reconstruction of a ridge as the result of and at the same time as a tumor removal (for other than dental purposes)
Payment for the wiring of teeth when it is done in connection with the reduction of a jaw fracture.
Dental splints are covered if used in conjunction with the treatment of a covered medical condition (i.e., dislocated upper and/or lower joints).
Medicare makes payment for a covered dental procedure no matter where the service is performed. The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure.
Payment may also be made for services and supplies furnished incident to covered dental services. For example, the services and supplies of a dental technician or nurse who is under the direct supervision of the dentist or physician are covered if the services are included in the dentist’s or physician’s bill.
Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.
For counseling regarding what is covered by Medicare call 1(800) MEDIGAP (633-4427). Our Customer Care Representatives are standing by to help you with any questions you may have.