Dental

Medicare Coverage Exclusion: Dental Services

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Medicare Coverage Exclusion: Dental Services

It is imperative that our providers are educated regarding the exclusion of dental services from the Medicare Program. Medicare generally does not cover dental services. Since the inception of Medicare, dental services including routine dental care have been excluded as a benefit. Understanding this will ensure that providers are submitting compliant claims and also help in preventing unnecessary claim denials. Please update any applicable policies/procedures as needed with this information.

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Dental Services Excluded Under Medicare Part B

The following two categories of services are excluded from coverage:

  • A primary service provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth, e.g., preparation of the mouth for dentures, removal of diseased teeth in an infected jaw.

Note that the structures directly supporting the teeth are the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and the alveolar bone (i.e., alveolar process and tooth sockets).

When an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty. For example, the extraction of an impacted tooth is not covered.

  • A secondary service that is related to the teeth or structures directly supporting the teeth unless it is incident to an integral part of a covered primary service that is necessary to treat a non-dental condition (e.g., tumor removal) and it is performed at the same time as the covered primary service and by the same physician/dentist. In those cases in which these requirements are met and the secondary services are covered, Medicare does not make payment for the cost of dental appliances, such as dentures, even though the covered service resulted in the need for teeth to be replaced, the cost for preparing the mouth for dentures, or the cost of directly repairing teeth or structures directly supporting teeth (e.g., alveolar process).

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Exceptions to Dental Service Exclusion

In these situations, dental services may be needed during the treatment of other diseases, and coverage may be possible:

  • The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.
  • An oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery or performed in a RHC/FQHC prior to a heart valve replacement.

In 1980, there was another exception made for inpatient hospital services where the dental procedure itself made hospitalization necessary.

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.

The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure.

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Inpatient Services in Connection With Dental Procedures

When a patient is an inpatient of a hospital for a dental procedure and the dentist's service is covered under Part B, the inpatient hospital services furnished are covered under Part A. For example, both the professional services of the dentist and the inpatient hospital expenses are covered when the dentist reduces a jaw fracture of an inpatient.

When the hospital services are covered, all ancillary services such as X-rays, administration of anesthesia, use of the operating room, etc., are covered.

Even if the inpatient hospital services are covered, the medical services of physicians furnished in connection with non-covered dental services are not covered.

Note: Anesthesiologists, radiologists, or pathologists whose services are performed in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth are also not covered.

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Modifier GY

Providers should be aware of the guidelines for submitting the noncovered outpatient dental service for a denial when the patient has supplemental insurance or if a denial is needed for any other reason.

Modifier GY is reported when submitting a Medicare claim for the statutorily excluded service in order to receive a formal denial for purposes of billing the supplemental insurance company.

Additionally, the modifier “GY” must be appended to a service(s) when the item or service is included on a claim and is statutorily excluded or does not meet the definition of any Medicare benefit.

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Revised 10/12/2023