By Wey-Wey Kwok
Although Medicare insurance broadly excludes coverage for dental services, it has been clarified that payment may be made for dental services that are inextricably linked to, and substantially related and integral to the clinical success of certain covered medical treatments, including treatment of head and neck cancers. 42 C.F.R. 411.15(i).
As of 2024, Medicare rules expressly permit payment for a dental or oral examination performed as part of a comprehensive workup before an individual undergoes head and neck cancer treatment involving radiation, chemotherapy, surgery, or any combination of these. Importantly, Medicare payment is also available for medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with, and medically necessary diagnostic and treatment services to address dental or oral complications after such head and neck cancer treatments. 42 C.F.R. 411.15(i).
Medicare may pay for dental services in these contexts if the dental provider is enrolled to participate in and bill Medicare. Additionally, there must be documented evidence of care coordination between the patient’s medical provider (e.g., oncologist) and dental provider, such as a referral or exchange of information. Persons enrolled in Medicare Advantage (MA) plans that include extra dental benefits should be careful to double-check that their in-network dentist participates in Medicare before receiving the medically necessary treatment under this policy. Many in-network dentists have opted out of Medicare.
Because Medicare’s dental payment clarification is a relatively recent development, significant questions remain about the scope and limitations of coverage and the requirements for billing. For instance, providers and patients want to know more precisely how long after head and neck cancer treatment Medicare would pay for services to address the dental and oral complications of that treatment, and more specifically, what services are and are not covered. On these and other issues, providers may seek guidance from the Medicare Administrative Contractor (MAC) for their state. More information about the dental payment policy, provider enrollment, and claims submission procedures can also be found on Medicare’s website.
Wey-Wey Kwok is a senior attorney at the Center for Medicare Advocacy, a nonprofit law organization that provides legal analysis, education, and advocacy to advance access to comprehensive Medicare coverage, health equity, and quality health care for older people and persons with disabilities.
