It is generally assumed that Medicare does not cover dental services.
However, in situations where the dental services are not "routine," Medicare
coverage may be available. Recognizing these situations, and understanding
how to characterize them in claims, will enhance beneficiaries' ability to
obtain coverage of needed services.
The Medicare statute excludes coverage of dental services in the following
payment may be made [by Medicare] . . . for any expenses
incurred for items or services – . . . where such expenses are
for services in connection with the care, treatment, filling,
removal, or replacement of teeth or structures directly
supporting teeth . . . 42 U.S.C. § 1395y(12).
This language excludes coverage of ordinary dental services, and Congress placed
it in a section of the Medicare statute that excludes coverage of a number of
other medical services that are generally considered to be routine, such as
common screening tests, personal comfort items, physical checkups, eyeglasses,
hearing aids, and immunizations that are not specifically covered. For
this reason, the Medicare statute can be read as allowing coverage of dental
services that are not "routine," such as the special care necessitated by the
effects of radiation and chemotherapy treatments prescribed to treat oral, head
and neck cancer.
This interpretation is supported by legislative history. The Senate Report
of 1965 explained that:
Payments would not be made for routine physical examinations or
for eyeglasses, hearing aids, or the fitting expenses or other
costs incurred in connection with their purchase. The
committee bill provides a specific exclusion of routine dental
care to make clear that the services of dental surgeons covered
under the bill are restricted to complex surgical procedures.
Thus…a routine annual or semiannual checkup would not be
covered…Similarly, too, routine dental treatment - filling,
removal, or replacement of teeth or treatment of structures
directly supporting teeth - would not be covered. S.Rep. No.
89-404 (1965), reprinted in 1965 U.S.C.C.A.N. 1943, 1989-1990
Medicare Agency Policy
The Medicare Benefits Policy Manual (MBPM), CMS Pub 100-02 at
www.cms.gov/manuals, allows for exceptions to the usual exclusion of
dental services. It specifies that a service should be covered if it is
"incident to and an integral part of a covered service performed by the
dentist." An application of this "incident to and an integral part of"
rule that is provided in the Manual is reconstruction of a ridge that can be
used to prepare the mouth for dentures if it is done at the same time as
surgical removal of a tumor, but not if it occurs afterwards. MBPM, Chap. 15, §
The MBPM also allows Medicare coverage of certain other dental services that are
related to cancer treatment. For example, Medicare will cover the
extraction of teeth to prepare the jaw for radiation treatment of neoplastic
disease. However, the MBPM manual warns that coverage of such extractions
is an exception to the usual rule that the dental service must be "incident to
and an integral part of a covered procedure or service performed by the
dentist." MBPM, Chap.16, § 140. Coverage of such an extraction is considered
an exception because the extraction does not occur simultaneously with the
radiation treatment. Thus, the Centers for Medicare & Medicaid Services
(CMS) admits that the "incident to and an integral part of" requirement is not
Some helpful clues as to how dental services should be structured in order to
obtain Medicare coverage can be found in court decisions. Although the
courts in these cases have not agreed in their outcomes, with some ordering
coverage and some upholding the Medicare agency's denial of coverage, their
reasoning provides some guidelines for beneficiaries and their advocates.
The court's decision in Currier v. Thompson, 369 F.Supp. 67, 71 (D.Me. 2005),
did not directly involve dental services but supports an interpretation of the
Medicare statute as excluding coverage of dental services only in routine
situations. Plaintiff Currier needed a video monitor to enhance his vision
because he suffered from macular degeneration. The court ruled that the
statutory exclusion of coverage for eyeglasses and dental services applies only
to Medicare coverage of routine eye and dental care. It based this
decision on the language of the statute itself, as well as the statements
Congress made about what it intended in the statute. Since the video
monitor was not "routine" eye care, the court reasoned that the Medicare statute
did not preclude coverage
Wood v. Thompson, 246 F.3d 1026 (7th Cir. 2001), resulted in an unfavorable
decision, but the court's reasoning opens the door to more liberal coverage
decisions. The appeal was brought by an individual who required dental
extractions prescribed before heart valve surgery because of the risk of
infection posed by his severe periodontal disease. The court first held
that the exclusion of dental services in the Medicare statute is ambiguous, and
thus it could proceed to conduct an analysis of the agency rule in the Medicare
Benefits Policy Manual. However, the court then found that the exclusion
of coverage in the MBPM was reasonable. Another court in a different
situation could examine the inconsistent rules in the MBPM, and refuse to apply
the "incident to and an integral part of" requirement.
Another appeal produced a mixed result. Chipman v. Shalala, 894 F.Supp.
392 (D.Kan. 1995), aff'd 90 F.3d 421 (10th Cir. 1996), was brought by a
beneficiary who needed bone augmentation surgery and dental implants to correct
atrophy of the jaw with ensuing chronic pain and nutritional deficits.
The administrative law judge held that the bone augmentation surgery was not
subject to the dental services exclusion but the implants were. On appeal,
the court held that Medicare was justified in denying coverage of the
beneficiary's porcelain veneer crowns because they were not "incident to or an
integral part of" the covered bone augmentation surgery.
However, the timing requirement of the "incident to and an integral part of"
criterion in the MBPM need not be determinative. This is illustrated by
two apparently contradictory judicial decisions, as follows.
First, Bick v. Secretary of Health and Human Services, 1996 WL 393656 (C.D.Cal.
1996), was brought by a beneficiary who needed root canals and crowns because of
damage to his gums following radiation treatments for head and neck cancer.
The court gave "considerable deference" to the Medicare Carrier Manual (a
predecessor to the MBPM), and found that Bick's dental procedures were not
"incident to or an integral part of" the radiation treatments. The facts
underlying this finding were: 1) the dental procedures were performed four years
after the appellant's radiation treatments, and 2) the dental services were not
provided or prescribed by his oncologist.
Second, Maggio v. Shalala, 40 F.Supp.2d 137 (W.D.N.Y. 1999), was brought by a
beneficiary who needed crowns and prosthesis to address nutritional deficiencies
affecting his treatment for leukemia and thrombocytopenia. The court found
that the dental services at issue were "incident to
and an integral part of" the covered treatment that the beneficiary was
receiving for his leukemia. A key fact was the role of the claimant's
primary oncologist, who directed and supervised the dental services This
decision provides an excellent precedent for coverage of dental care resulting
from radiation treatments, because the court refused to interpret the "incident
to and an integral part of" language as limiting coverage to dental services
provided at the same time and by the same provider as the underlying treatment.
Increasing the Possibilty of Coverage
The likelihood of obtaining Medicare coverage for non-routine dental care can be
increased by taking certain steps. First, a treatment plan established at
the outset by the primary physician providing covered medical services should
include provision for ancillary dental care. As dental services are
needed, the physician should record the fact that they are incident to and
necessary for the patient's primary treatment, and prescribe the specific dental
services. This will take such dental services out of the exclusion for
routine care, and show that they are "incident to and
an integral part of" a covered course of treatment.
In order to obtain a successful decision, it may be necessary for the
beneficiary to go through a number of unsuccessful lower levels of
administrative appeal before reaching the ALJ or federal court levels. At
these higher levels of appeal, the beneficiary or her advocate will have an
opportunity to overcome the presumption that Medicare never covers dental
services. Testimony and medical records from the beneficiary's
physicians should be presented to show that the dental services were ordered and
supervised by them as part of the claimant's covered treatment.
Legal arguments can be made that 1) the controlling Medicare statute, as shown
by its legislative history, excludes only coverage of routine dental services;
2) the manual requirement that services be "incident to and an integral part of"
covered services was met; or if not met, 3) the interpretations of the statute
in the manual are too inconsistent and unreasonable to be given deference.
Memorandum of Law in Support of Appeal Regarding Medicare Coverage of
Medical-Related Dental Services (.pdf will open in a new window)
Favorable Decision by
Administrative Law Judge in Appeal of Medical Related Dental Services (.pdf
will open in a new window. File is large, and will take some time.)