We know that original Medicare Part B does not pay for the care, treatment, filling, removal, or replacement of teeth for adults. In other words, it does not include dental benefits.
At the same time, Medicare Part C (Advantage Plans) often covers routine dental services but with extremely low annual maximums.
However, the Medicare health insurance component will cover dental work when an integral part of another covered medically necessary procedure.
Meanwhile, oral and maxillofacial surgeons are licensed dentists and medical doctors who routinely bill health insurance for covered services, meaning they could get Medicare to pay for many procedures, depending on the reason.
Medicare Advantage Plans
Medicare Advantage Plans (Part C) cover oral surgery for adults more frequently because these policies often pay for dental work – although with puny annual maximums that limit benefits severely.
Medicare Advantage combines Parts A (hospital), B (medical), D (prescription drugs), and sometimes dental care into one policy managed by a private insurance company.
Dental Implants
Medicare Advantage plans might cover oral surgery for dental implants under the medical and oral care umbrella. Pay close attention and file your claims correctly to avoid unnecessary denials or delays.
Medicare Part C might pay for dental implant services performed by an oral surgeon under two narrowly defined circumstances.
- Medical reasons: do not limit annual benefits but require a letter of medical necessity with a narrative describing the disease or accident causing tooth loss
- Prevent further bone atrophy caused by diseases such as diabetes, digestive disorders, or osteoporosis.
- Restore chewing function after a non-biting accident fractures the jaw and dislodges teeth.
- Replace teeth extracted before radiation treatment for cancers of the head, neck, and jawbone.
- Lack of dentition worsens digestive disorders such as gastric reflux or ulcerative colitis.
- Prescription drugs covered by the plan caused dry mouth and decay, leading to tooth loss.
- Oral care reasons: does not require a letter of medical necessity connecting to a covered disease or accident but is subject to annual maximum benefit limitations
Gum Surgery
Medicare Advantage plans might cover oral surgery for periodontal (gum) procedures but only under the dental insurance umbrella subject to the annual maximum – if available in your state.
Choosing a dentist or oral surgeon who accepts Medicare can save you a bundle because in-network providers agree to charge the discounted “allowed amount,” whereas those out-of-network have no contractual restrictions.
Gum disease treatment costs frequently outstrip the annual maximum benefit baked into Advantage plans, so do not overlook the hidden discounts built into using a Preferred Provider Organization (PPO).
Medicare Part B
Original Medicare Part B pays for specific oral surgery procedures under its healthcare umbrella but denies claims typically covered by dental insurance alone.
Part B covers services or supplies outside of a hospital to diagnose or treat your medical condition.
Dentures
Medicare Part B might cover denture-related oral surgery when you need a tooth extracted for a medically necessary reason (see below). However, CMS explicitly states that it does not pay to replace missing teeth.
Medicare seniors might receive zero-cost dentures when dual-eligible for Medicaid. This second government-sponsored program pays for false teeth in thirty-three states, including several with the largest populations.
About 20% of Medicare enrollees are dual-eligible for Medicaid. Make sure you take full advantage of both programs if you qualify.
Tooth Extractions
Medicare Part B will cover oral surgery for tooth extractions for adults when they fall under the healthcare category. The removal must be an integral part of another medically necessary covered service.
Wisdom Teeth
Medicare Part B often pays for oral surgery for bone-impacted wisdom tooth extractions, which are medically necessary because they can cause pain and infection and develop cysts.
Medical insurance covers bone-impacted wisdom tooth removal, and Medicare Part B follows similar guidelines. Of course, only young adults (not seniors) have their wisdom teeth removed, typically before their 25th birthday. Those adults with disabilities who can work part-time become eligible for Medicare after two years.
Before Radiation
Medicare Part B also pays for oral surgery for tooth extractions in preparation for radiation therapy for neoplastic diseases (cancer) involving the jaw. The preliminary steps become integral because cancer treatment is a covered service (medically necessary).
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.
Caused by Accidents
Medicare Part B will also pay for oral surgery for conditions caused by non-biting accidental injury. For instance, the Centers for Medicare and Medicaid explicitly illustrate the reconstruction of a broken jaw as an example of a covered service.
By extension, we can infer that the extraction of broken teeth caused by accidents would also fall into this category.
Jaw Surgery
Medicare Part B may cover oral surgery for corrective jaw (orthognathic) procedures that treat a recognized medical condition. Cosmetic operations that improve appearance do not meet the criteria.
The key to getting any insurance to cover orthognathic surgery is a well-documented letter of medical necessity, which should include a narrative summarizing the diagnosis, rationale for treatment, proposed operative report, and the expected outcome.
Below are examples of orthognathic procedures that might qualify.
- Mandibulectomy to remove cysts and cancerous tumors before they metastasize and spread to other parts of your body
- Correction of significant congenital deformities such as a cleft palate, micrognathia (small mandible), or agnathia (absence of the condyloid process)
- Removal of osteonecrosis of the jaw (ONJ) to excise dead (necrotic) bone exposed in the mouth
Biopsies
Medicare Part B will likely cover oral surgery for a biopsy to detect cancer because procedures meant to diagnose malignant tumors fall into the medically necessary category. The health insurance component kicks in.
In a biopsy, the surgeon takes a small tissue sample from your cheek, lip, palate, gum, tooth, tongue, or jaw for further study in a lab to determine if the tumor or cyst is malignant or benign.
Final Thoughts
As you can see, Medicare often covers oral surgery for adults. A letter of medical necessity is critical to getting the health insurance component to pay for most of your expenses without an annual maximum limiting your benefits.
Work with your surgeon to compile a well-documented narrative.
