Page 147 - Medicare Benefit Policy Manual

underlying medical condition and clinical status or because of the severity of the dental
procedure, requires hospitalization in connection with the provision of such services.

There are some other instances where medical services necessary to diagnose and treat the
individual’s underlying medical condition may require the performance of certain dental services
and the dental exclusion may not apply. Dental services that are inextricably linked to, and
substantially related and integral to the clinical success of, certain covered medical services are
not excluded. Such non-excluded dental services could include dental and oral examinations as
well as medically necessary diagnostic and treatment services to eliminate an oral or dental
infection. We note that the necessary treatment to eradicate an infection may not include the
totality of recommended dental services for a given patient. For example, if an infected tooth is
identified in a patient requiring an organ transplant, cardiac valve replacement, or valvuloplasty
procedure, the necessary treatment would be to eradicate the infection, which could result in the
tooth being extracted. Additional dental services, such as a dental implant or crown, may not be
considered immediately necessary to eliminate or eradicate the infection or its source prior to
surgery. Therefore, such additional services would not be inextricably linked to, and
substantially related and integral to the clinical success of, the organ transplant, cardiac valve
replacement, or valvuloplasty services. As such, no Medicare payment would be made for the
additional services that are not immediately necessary prior to surgery to eliminate or eradicate
the infection.

Payment may be made under Medicare Parts A and B for dental services, prior to or, in certain
circumstances, contemporaneously with, certain covered medical services furnished in the
inpatient or outpatient setting. Scenarios in which Medicare payment for dental services is not
excluded include, but are not limited to, the examples below.

EXAMPLE 1:

Dental or oral examination performed as part of a comprehensive workup in either the inpatient
or outpatient setting prior to Medicare-covered organ transplant, cardiac valve replacement, or
valvuloplasty procedures; and, medically necessary diagnostic and treatment services to
eliminate an oral or dental infection prior to, or contemporaneously with, the organ transplant,
cardiac valve replacement, or valvuloplasty procedure. For purposes of this manual only,
hematopoietic stem cell and bone marrow transplants have a similar risk of infection to organ
transplants, and an oral examination and subsequent necessary diagnostic and treatment services,
performed in either the inpatient or outpatient setting would be payable under this example. (The
term “organ transplant” may not be considered to include bone marrow or hematopoietic stem
cell transplants in all contexts. These services are not considered organs for purposes of the
definition of organs in 42 CFR 486.302 or Medicare payment policies for organ procurement
organizations.)

EXAMPLE 2:

The reconstruction of a ridge performed as a result of and at the same time as the surgical
removal of a tumor. The reconstruction of a ridge performed primarily to prepare the mouth for
dentures is a noncovered procedure.