Will Medicare cover hospitalization after oral surgery?

1 answer | Last updated: Sep 20, 2016
Jrz asked...

Several teeth are broken at gum line, roots are diseased and must come out with other diseased teeth. Patient has Congestive Heart Failure so Oral Surgeon wants to hospitalize patient due to risks. Will Medicare cover hospital? I know they won't pay for oral surgeon.

Expert Answers

As you realize from what you say in your question, Medicare does not normally cover oral surgery unless it involves bones, the jaw, or facial nerves rather than simply teeth, and is the kind of procedure than an MD (medical doctor) would perform, rather than a dentist or non-physician oral surgeon. So, in this case Medicare is not likely to cover the oral surgery itself -- the doctor's bill or the hospital's charges for cost of surgery, if it's performed in the hospital. However, if the patient's medical condition -- meaning his heart condition -- makes it "medically necessary" for him to be an inpatient in the hospital during and following the surgery, then Medicare Part A might cover the hospital charges for his inpatient care.

The key here is convincing Medicare that inpatient hospital care is medically necessary. That would involve providing Medicare with medical records and communications not just from the patient's oral surgeon but also from the patient's cardiologist (heart specialist) or other physician who is treating the patient for the heart condition. (The cardiologist or treating physician would probably have to be directly involved in having the patient admitted to the hospital.) If the patient wants to know ahead of time whether Medicare will pay for the hospitalization, the oral surgeon and the other doctors treating the patient should submit the request for coverage to Medicare before the surgery is scheduled. Then Medicare can request whatever documentation it wants to see, and can give a decision on coverage before the surgery happens.