Medicare Payment Provisions for Dental Services as Finalized in the Calendar Year 2023

As indicated under the general exclusions from coverage in 42 CFR 411.15(i), and subject to exceptions, items and services, in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered. “Structures directly supporting the teeth” means the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. Two statutory exceptions to this policy allow for Medicare payment for inpatient hospital services in connection with the provision of dental services if the individual, because of the individual’s 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.

There are some other instances where medical services necessary to diagnose and treat the individual’s underlying medical condition may require the performance of certain dental services and the dental exclusion may not apply. Dental services that are inextricably linked to, and substantially related and integral to the clinical success of, certain covered medical services are not excluded. Such non-excluded dental services could include dental and oral examinations as well as medically necessary diagnostic and treatment services to eliminate an oral or dental infection. 

We note that the necessary treatment to eradicate an infection may not include the totality of recommended dental services for a given patient. For example, if an infected tooth is identified in a patient requiring an organ transplant, cardiac valve replacement, or valvuloplasty procedure, the necessary treatment would be to eradicate the infection, which could result in the tooth being extracted. Additional dental services, such as a dental implant or crown, may not be considered immediately necessary to eliminate or eradicate the infection or its source prior to surgery. Therefore, such additional services would not be inextricably linked to, and substantially related and integral to the clinical success of, the organ transplant, cardiac valve replacement, or valvuloplasty services. As such, no Medicare payment would be made for the additional services that are not immediately necessary prior to surgery to eliminate or eradicate the infection. 

Payment may be made under Medicare Parts A and B for dental services, prior to or, in certain circumstances, contemporaneously with, certain covered medical services furnished in the inpatient or outpatient setting. 

CMS has provided scenarios in which Medicare payment for dental services is not excluded include, but are not limited to, the examples in Medicare Benefit Policy Manual, Chapter 15 (PDF), Section 150 .

When covered, facilities should utilize existing claims submission procedures, including the use of HCPCS modifiers, e.g., Modifier GY for noncovered Medicare services when a Medicare claim denial is sought for submission to third party payers.   

Medical Review

PalmettoGBA currently has a Local Coverage Determination (LCD) for Dental Services L34574 and Local Coverage Article A59449 regarding dental services.

Additional, specific medical review activity related to covered Medicare Dental Services may be provided later.

Integration and Coordination Between Dental and Medical Professional

CMS reminds providers of the requirement for integration and coordination between dental and medical professionals.

Integration between medical and dental professionals can occur when these professionals coordinate care. This level of coordination can occur in various forms such as, but not limited, to a referral or exchange of information between the medical professional (physician or non-physician practitioner) and the dentist. This coordination should occur between a dentist and another medical professional (physician or other non-physician practitioner) regardless of whether both individuals are affiliated with or employed by the same entity. Without both integration between the Medicare enrolled medical and dental professional, and the inextricable link between the dental and covered medical services, dental services fall outside of the Medicare Part B benefit as they would be in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth within the meaning of section 1862(a)(12) of the Act; though they may be covered by types of supplemental health or dental coverage. This is because the medical and dental professionals would not have the necessary information to decide that the dental service is inextricably linked to a covered medical service, and therefore, not subject to a statutory payment exclusion under section 1862(a)(12) of the Act.

Resources

• Medicare Benefit Policy Manual, Chapter 15 (PDF), Section 150
• Change Request 13190 (PDF)
• Change Request 13181 (PDF)
• Medicare Dental Coverage
• 42 CFR § 411.15(i) Dental Services