Medicare currently covers dental work that is necessary for the completion of another covered procedure (such as jaw reconstruction after an accident) or that is performed in preparation for radiation therapy for neoplastic diseases of the jaw. Under certain conditions, Medicare will also cover oral exams, but not treatment, prior to a kidney transplant or heart valve replacement. When conducted by a dentist employed by the hospital, this type of examination would fall under Part A coverage, and when conducted by a physician, it would fall under Part B coverage.
Statutory Dental Exclusion
According to Section 1862 (a)(12) of the Social Security Act, “payment may be made under part A in the case of 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 his dental condition, requires inpatient hospital services in connection with the provision of such dental services.”
Background
Medicare originally implemented the dental exclusion. Congress did not limit the dental exclusion to routine dental services like they did with routine medical checkups and foot care when they established the exclusion; rather, they included a blanket exclusion of dental services.
Since 1980, when it made an exception for inpatient hospital services when the dental procedure itself necessitated hospitalisation, Congress has not amended the dental exclusion.
Coverage Principle
Dental care coverage is determined not by the cost or importance of the service rendered, but by the nature of the service rendered and the location of the anatomical structure being treated.
Services Excluded under Part B
Coverage is not provided for the following two types of services:
Care, treatment, removal, or replacement of teeth or structures directly supporting teeth, such as preparing the mouth for dentures or removing diseased teeth from an infected jaw. This can be done for a variety of reasons and can be considered a primary service.
Unless it is an incidental and integral part of a covered primary service that is necessary to treat a non-dental condition (such as tumour removal), a secondary service that is related to the teeth or structures directly supporting the teeth is not covered by insurance. Even if the covered service directly caused the need for the replacement of teeth, the cost of preparing the mouth for dentures, or the cost of directly repairing teeth or structures directly supporting teeth, Medicare will not pay for these procedures unless the patient has met the aforementioned requirements and the secondary services are covered (e.g., alveolar process).
Exceptions to Services Excluded
Preparing the jaw for radiation therapy for neoplastic disease by removing teeth.
As part of the pre-operative process for a renal transplant or a heart valve replacement, an in-patient oral or dental examination may be performed.
Definition
The periodontium, which consists of the gingivae, periodontal membrane, cementum of the teeth, and the alveolar bone, is the structures directly supporting the teeth (i.e. alveolar process and tooth sockets).
