Page 32 - Medicare Benefit Policy Manual

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.

150 - Services Reimbursable Under Automobile, No Fault, Any Liability
Insurance or Workers’ Compensation
(Rev. 1, 10-01-03)