Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

Dental/Oral Health

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Table Of Contents
  1. Medicare Coverage of Dental Services
  2. VIDEO: The Impact of Oral/Dental Health on the Treatment of Medical Conditions
  3. VIDEO: Medically Necessary Dental Care
  4. Fact Sheets
  5. Articles and Updates

Medicare Coverage of Dental Services

Medicare law broadly excludes payment for dental services, i.e., “services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth.” Section 1862(a)(12) of the Act. The statute includes an exception that allows payment for inpatient hospital services in connection with dental services when hospitalization is required because of: (1) the individual’s underlying medical condition and clinical status; or (2) the severity of the dental procedure. 

Dental Services that are “Inextricably Linked” to Covered Medical Services

Through its CY 2023 Physician Fee Schedule (PFS) rulemaking, the Centers for Medicare & Medicaid Services (CMS) clarified and codified that dental services that are “inextricably linked to, and substantially related and integral to the clinical success of a certain covered medical service are not excluded; payment may be made under Medicare Parts A and B for services furnished in the inpatient or outpatient setting.” 42 C.F.R. § 411.15(i)

In the regulation, CMS provides examples of clinical scenarios in which “inextricably linked” dental services may be paid.  These include a dental or oral examination performed as part of a comprehensive workup prior to, and medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to, or contemporaneously with the following Medicare-covered services:

  • Organ transplant (including hematopoietic stem cell and bone marrow transplant).
  • Cardiac valve replacement and valvuloplasty procedures.
  • Chemotherapy, chimeric antigen receptor (CAR) T-cell therapy, and administration of high-dose bone modifying agents (antiresorptive therapy) when used to treat cancer.
  • Dialysis services when used in the treatment of ESRD.
  • Treatment of head & neck cancer using radiation, chemotherapy, surgery, or any                 combination thereof).  Note: payment may also be available for dental services to address dental or oral complications after head and neck cancer treatment.

Moreover, the coverage exclusion does not apply to the following services:

  • Dental ridge reconstruction done as a result of and at the same time as surgery to remove a tumor.
  • Services to stabilize or immobilize teeth related to reducing a jaw fracture.
  • Dental splints, only when used as part of covered treatment of a covered medical condition such as dislocated jaw joints.
  • Tooth extraction to prepare the jaw for radiation treatment of neoplastic disease.

Medicare may pay for dental services in the above contexts if there is documented care coordination between medical and dental provider, such as a referral or exchange of information.  Payment may also be made for ancillary services and supplies incident to these services, whether performed in the inpatient or outpatient setting, including, but not limited to the administration of anesthesia, diagnostic x-rays, use of operating room, and other related procedures.

Medicare also covers certain medical procedures that dentists are licensed to perform, such as biopsies for oral cancer.  Additionally, local coverage determinations in certain geographic regions may cover certain dental items and services (e.g., oral sleep apnea appliances), provided that specific criteria are met.

How can Providers Participate?

Providers who furnish covered items and services to Medicare beneficiaries and wish to bill Medicare must enroll in Medicare.  Enrollment and claims submission procedures are outlined on CMS’s website here, along with more information about the payment policy.

Providers who have formally opted out of Medicare may not bill Medicare for covered services. Such providers must give their Medicare-eligible patients notice that they have opted out of Medicare and have them sign a private contract before furnishing covered services.

Dental Services and Medicare Advantage Plans

Medicare Advantage (MA) plans must provide Medicare-covered benefits to their enrollees.  Many MA plans also offer extra benefits that Original Medicare does not cover, such as routine dental services. We recommend that beneficiaries who are considering enrolling in an MA plan carefully review the coverage terms and limitations on the dental benefits being offered. They may also want to inquire more about the location and actual availability of dental providers participating in the plan’s network.  In-network dental providers can be reimbursed for furnishing the outlined dental benefits offered by the plan. But, to be reimbursed for furnishing covered “inextricably linked” dental services to an enrollee, the provider must also be enrolled in Medicare.

VIDEO: The Impact of Oral/Dental Health on the Treatment of Medical Conditions

VIDEO: Medically Necessary Dental Care

A compelling short video with clinician and patient interviews that help clarify why dental care can be medically necessary, and the adverse personal as well as fiscal consequences when such treatment is unaffordable and uncovered.

Fact Sheets

Articles and Updates

For older articles, see our article archive.