Overview of Medicare Dental Coverage
Currently, there is Medicare dental coverage for procedures such as rebuilding of the jaw after an accidental injury, or for the extractions which were performed in preparation for treatment of radiation for neoplastic diseases that involve the jaw. Additionally, Medicare dental coverage also provides oral examinations before a heart valve replacement or kidney transplant, under specific circumstances. Also, Medicare dental coverage is provided underneath Part A if done by a dentist within the hospital’s staff or underneath Part B if done by a doctor.
Statutory Dental Exclusion
The Social Security Act, section 1862 (a) (12) says that, “where such expenses are for the services linked with the replacement, care, treatment, filling or removal of teeth or structures which directly support the teeth, except that payment might be rendered underneath part A in the instance of inpatient hospital services linked with the providing of such dental services if the person, because of the clinical status or underlying medical condition or due to the severity of the dental treatment, needs hospitalization linked with the provision of such services.”
The exclusion of dental was involved as a portion of the first Medicare plan. When setting up the exclusion of dental, the Congress didn’t put a limitation on the exclusion of dental services that were routine, as it did for foot care that was routine or for routine physical checkups, instead, it involved an exclusion of dental services.
Since the year 1980, Congress hasn’t amended the exclusion of dental. While it made an exception for the inpatient hospital services, the dental treatment itself made the hospitalization required.
Principle of Coverage
Medicare dental coverage isn’t decided by the necessity or value of dental care but the anatomy structure on which the treatment is done and the kind of service offered.
Services Which are Excluded Underneath Part B
The following 2 service categories are excluded from Medicare dental coverage:
The primary service (regardless of complexity or cause) offered for the replacement, removal, treatment or care of teeth or structures which directly support the teeth, e.g., removal of teeth which are diseased in an infected jaw or preparing the mouth for dentures.
The secondary service which is related to the teeth or structures that directly support the teeth unless it’s incident to and an integral portion of a covered primary service which is needed to treat a non-dental state (that is, removal of a tumor) and it’s done at the very same period of time as the primary service that is covered and by the exact dentist/physician. In these instances that these requirements are met and all secondary services have been covered, Medicare doesn’t make payment toward the price of dental appliances, like dentures, although the service which is covered have resulted in the necessity for the replacement of the teeth, the price of the preparation of the oral cavity for the dentures, the price of repairing teeth directly or structures which directly support your teeth (that is, alveolar process).
The Exceptions to the Excluded Services
- Teeth extractions in preparation of a jaw for treatment of radiation for neoplastic diseases.
- A dental or oral exam done on an inpatient foundation as a portion of the comprehensive workup before renal transplant surgery or done in a FQHC/RHC before the replacement of a heart valve.
Structures which directly support all teeth means a periodontium, which involves the gingivae, cementum of the teeth, the bone of the alveolar (that is, tooth sockets and alveolar process), and the periodontal membrane.