The Centers for Medicare & Medicaid Services (CMS) announced this week that it will not codify additional examples of clinical scenarios in which dental services may be paid by Medicare as part of its CY 2026 Physician Fee Schedule rulemaking.
Three years ago, CMS clarified and codified that Medicare payment can be made for dental services that are “inextricably linked to, and substantially related and integral to the clinical success of, other covered services.” 42 C.F.R. 411.15(i)(3). At that time, it specifically recognized payment for services needed to identify and eradicate dental infections prior to and contemporaneous with organ transplant and cardiac valve replacement and repair surgeries. CMS also established an annual process whereby it would consider other clinical examples nominated by the public. As a result, the regulation now also recognizes payment for dental services necessary to the treatment of head and neck cancer, certain treatments for other cancers, and patients with End Stage Renal Disease who will begin or are undergoing dialysis.
The Center for Medicare Advocacy has worked with a consortium of interested stakeholders and advocacy groups to advance and implement the dental payment policy. We have supported recommendations that Medicare pay for dental services necessary to effectively treating and/or managing certain autoimmune disorders, diabetes, and diabetic retinopathy and nephropathy. Although CMS does not intend to recognize additional clinical examples at this time, it provided assurance that it “will take the information and recommendations submitted into consideration for the future.”
- For more information about Medicare’s dental payment policy, click here.
July 17, 2025 – W. Kwok