In most cases, Original Medicare Part B does not cover dental services like cleanings, fillings, extractions, bridges, or dentures.
Medicare Part C (Advantage Plans) often covers routine dental services but has low annual maximums, so they pay little.
Oral and maxillofacial surgeons are medical doctors who operate on the head, neck, face, jaws, and mouth. They bill medical and dental insurance for their services.
Expect to find many unclear areas. Medicare covers some oral surgeries but denies benefits for others. Learn from examples of procedures that are covered and those that are not.
Oral Surgeries Medicare Denies
Medicare Part B usually denies dental procedures performed by oral and maxillofacial surgeons. The Centers for Medicare & Medicaid Services (CMS) does not classify these operations as reasonable or necessary to diagnose or treat an illness or injury.
Here are examples and tips on finding alternatives.
Dental Implants
Medicare does not cover dental implant procedures performed by an oral surgeon. CMS states that it does not pay to replace missing teeth.
Oral surgeons frequently perform extractions, bone grafting, alveoplasty, body placement, and implant insertion.
Seniors with Medicare and Medicaid might get coverage for these services if they live in New York or California. Medicaid rules in these states are more favorable for dental implants.
Some low-income seniors qualify for both programs.
Periodontal Disease
Medicare rarely covers oral surgery for periodontal disease, even though the infection can cause other health issues if it spreads. However, CMS allows some exceptions for other reasonable and necessary procedures.
Medicare might pay for gum surgery before a heart valve replacement, bone marrow transplant, organ transplant, or kidney transplant. Otherwise, the patient would have to pay for all other procedures themselves unless they have dental insurance.
Oral Surgeries Medicare Covers
Medicare Part B covers specific medical procedures performed by oral and maxillofacial surgeons that CMS deems reasonable and necessary for diagnosing or treating an illness or injury.
Below are several examples that typically fit this definition.
Tooth Extractions
Medicare sometimes covers tooth extractions performed by an oral surgeon. However, only a narrowly defined set of procedures qualifies as reasonable and necessary.
Wisdom Teeth
Medicare might pay for an oral surgeon to extract bone-impacted wisdom teeth. The procedure is reasonable and necessary because bone-impacted third molars cause pain and can develop cysts.
Medicare might pay 80% of the cost to remove wisdom teeth for young adults with disabilities who qualify after two years on Medicaid. Seniors over 65 rarely need this procedure.
Before Radiation
Medicare also pays for tooth extractions performed by an oral surgeon in preparation for radiation therapy for neoplastic diseases (cancer) involving the jaw. This procedure is reasonable and necessary to treat cancer.
Extractions before head and neck radiation reduce the risk of osteonecrosis of the jaws after therapy. Osteonecrosis is a disease caused by reduced blood flow to bones in the joints.
After Accidents
Medicare might also pay to extract teeth after a non-biting accident. CMS cites the reconstruction of a broken jaw as a reasonable and necessary procedure.
Following the same logic, emergency dental extractions might qualify for benefits. Have the oral surgeon file a claim with Medicare describing the accident in detail.
Do not expect benefits for extractions tied to tooth decay or gum disease.
Jaw Surgeries
CMS states that Medicare will pay for oral surgery to repair a broken jaw. But what about other orthognathic procedures needed to correct disease-related conditions?
A well-documented letter of medical necessity is key to getting insurance to cover orthognathic surgery. The document should include a narrative summarizing the diagnosis, rationale for treatment, proposed operative report, and expected outcome.
TMJ
TMJ Medicare rarely covers oral surgery to correct temporomandibular joint disorders (TMJ). CMS is more likely to consider less expensive treatments as reasonable and necessary, such as the following:
- Intra-oral appliances like occlusal guards and stabilization splints
- Physical therapy, such as jaw exercises, heat treatments, manipulation, and electrical stimulation
- Medications like anti-inflammatory drugs, low-dose tricyclic antidepressants for sleep, and other pain relievers
Jaw surgery for TMJ might qualify for Medicare only if you have tried these non-invasive treatments for at least four months. An MRI or CT scan must also show an intra-capsular condition.
Sleep Apnea
Medicare is unlikely to cover corrective jaw surgery for sleep apnea right away. CMS often considers continuous positive airway pressure (CPAP) devices reasonable and necessary.
Medicare covers CPAP machines during a three-month trial and may continue benefits if your doctor documents that the equipment is helping you sleep better.
Medicare might approve jaw realignment surgery to correct obstructive sleep apnea only after less invasive treatments have failed. Expect to complete a full-channel nocturnal polysomnography before approval.
Cancerous Lesions
Medicare is most likely to cover biopsies performed by an oral surgeon to test for the presence of cancer and the subsequent removal of malignant tumors. The diagnosis and treatment of cancer is reasonable and necessary.
Oral surgeons typically excise head, neck, face, jaw, and mouth cancers. Expect coverage for the removal of any malignant tumors.
