Knowledge Base Article

A recent television commercial shows an older gentleman with whom all the older ladies want to dance. He attributes his popularity with the ladies to his beautiful smile and perfect dentition. Unfortunately, older Americans will not be getting that perfect smile paid for by Medicare. Medicare does not cover dental services except in rare circumstances. That is a shame, because good dental health affects much more than just a person’s popularity. Poor dental hygiene also contributes to an increased risk for heart disease, stroke, dementia, respiratory problems, and diabetic complications.

Per the Social Security Act, Medicare does not cover items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures). Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed. Medicare only covers dental services if they are incident to and an integral part of a procedure or service that is covered by Medicare. For example, tooth extractions performed in preparation for radiation treatment for jaw cancer would be covered, but tooth extractions because of tooth decay are not.

The Office of Inspector General (OIG) has identified improper payments for non-covered dental services as a topic in their annual Work Plan since 2012. This March, the OIG released their report summarizing the results of audits of dental services’ payments for six Medicare Administrative Contractors (MACs). Those MACs are CGS, First Coast, NGS, Noridian, Novitas, and WPS. The audit report also includes recommendations CMS could implement to help ensure that future claims for hospital outpatient dental services meet Medicare coverage requirements.

The OIG selected a sample of 600 claims from a total of 15,690 hospital outpatient dental services for the six contractors, totaling $10,874,814 paid to providers during the period January 1, 2011, through December 31, 2014.  They did not include dental services associated with a diagnosis related to cancer or physical trauma because those services are generally eligible for Medicare payment. On the basis of their results, the OIG estimated that the six contractors improperly paid providers an estimated $9,783,023 for hospital outpatient dental services that did not comply with Medicare requirements. This is approximately 90% of the total dental service payments considered. The types of dental services performed and paid that are not covered by Medicare included:

• tooth socket repairs, generally performed in preparation for dentures,
• routine oral evaluations, x rays, and tooth extractions,
• excisions and gum repair (performed when removing inflamed gums and when reshaping healthy gums for a cosmetic or functional purpose), and
• periodontal osseous surgery (performed when treating gum disease).

The OIG recommended the implementation of national edits for hospital outpatient dental claims, but CMS did not concur with this recommendation since dental coverage is based on the specific clinical needs of the beneficiary. CMS does agree to work with its contractors to develop and strengthen local edits to help ensure that payments made to providers for dental services comply with Medicare requirements.

It pays to take care of your teeth when you are young, because once you reach Medicare age, you are on your own.