There are two ways in which Medicare now covers dental services: either as an integral element of an already-covered surgery (such as reconstructing a patient’s jaw following an accident) or as preparatory work for radiation therapy of jaw cancer. Before kidney transplantation or heart valve replacement, Medicare will cover oral examinations, but not treatment. Under Part A, a dentist or physician on the hospital’s staff would be able to do such an examination.
Statutory Dental Exclusion
“Where such expenses are for services in connection with dental care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services associated with the provision of such dental treatments if an individual, because of his underlying medical condition and clinical status or be”
Medicare’s original design included an exclusion for dental care. The dental exclusion was not limited to routine dental services, as it was for normal physical examinations or basic foot care, but was instead added as a blanket exclusion of dental services by Congress when it was established.
It has not been changed since 1980 when Congress granted an exception for inpatient hospital services for dental procedures that necessitated hospitalization.
It is not the value or necessity of the dental care that determines the insurance coverage, but rather the type of service offered and the anatomical structure on which the procedure is conducted that is covered.
Services Excluded under Part B
There are two types of services that are not covered by this policy:
Treatment, removal, or replacement of teeth or structures immediately supporting teeth as a primary service (regardless of reason or complexity), e.g., the preparation of the mouth for dentures, the removal of diseased teeth from an infected jaw.
Secondary services that are directly related to teeth or structures directly supporting teeth, unless they are incidental to and an intrinsic component of covered primary care that is necessary to address a non-dental ailment (e.g., tumor removal). When these conditions are met and secondary services are covered, Medicare does not pay for the cost of dental appliances, such as dentures, even if the covered service resulted in the need for teeth to be replaced, the cost of preparing the mouth for dentures, or the cost of directly repairing teeth or structures supporting teeth (e.g., alveolar process).
Exceptions to Services Excluded
Treatment of neoplastic illness requires removing teeth from a patient’s jaw.
As part of a comprehensive workup before kidney transplant surgery or before a heart valve replacement, an inpatient oral or dental examination is performed.
Gingiva, alveolar bone, and periodontal membrane are examples of structures directly supporting tooth structure (i.e. alveolar process and tooth sockets).