Dental Services Exclusion

140 - Dental Services Exclusion (Rev. 1, 10-01-03) A3-3162, HO-260.13, B3-2336 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 mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process. However, payment may be made for certain other services of a dentist. (See the Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services,” §150.) The hospitalization or nonhospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure. 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. Similarly, an alveoplasty (the surgical improvement of the shape and condition of the alveolar process) and a frenectomy are excluded from coverage when either of these procedures is performed in connection with an excluded service, e.g., the preparation of the mouth for dentures. In like manner, the removal of the torus palatinus (a bony protuberance of the hard palate) could be a covered service. However, with rare exception, this surgery is performed in connection with an excluded service, i.e., the preparation of the mouth for dentures. Under such circumstances, reimbursement is not made for this purpose. The extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease is also covered. This is an exception to the requirement that to be covered, a noncovered procedure or service performed by a dentist must be an incident to and an integral part of a covered procedure or service performed by the dentist. Ordinarily, the dentist extracts the patient’s teeth, but another physician, e.g., a radiologist, administers the radiation treatments. Whether such services as the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is covered. Thus, an x-ray taken in connection with the reduction of a fracture of the jaw or facial bone is covered. However, a single x-ray or x- ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered. See also the Medicare Benefit Policy Manual, Chapter 1, “Inpatient Hospital Services,” §70, and Chapter 15, “Covered Medical and Other Health Services,” §150 for additional information on dental services.