Will Medicare cover Dental if it is deemed medically necessary?

1 answer | Last updated: Sep 17, 2016
Brendadobbs asked...

I have MS and the injections that I must take for it has severly damaged my teeth. My doctor told me that this would happen when I started taking the Copaxone. Now my teeth have started to fall out and I have been getting a lot of absses. My dentist has said that all of my teeth need to come out before they cause me anymore serious health problems since my immune system is basically shot. He said that he would need to put me to sleep to remove all of them and it would be best for it to be done in a hospital so that they can monitor me due to the fact that I have problems with my throat closing up. My dentist mentioned that he has been told that Medicare will cover the cost or at least part if it was deemed necessary by a doctor. Is this true? Any help would be great at this point.

Expert Answers

It's possible that Medicare might cover all or part of your hospital oral surgey, but getting coverage is more complicated than simply having a doctor say that it's "necessary". First of all, there are two parts of Medicare involved: Part A, which could cover your inpatient hospital costs, and Part B, which could cover the services of the oral surgeon-dentist or doctor who performed the surgery.

Let's start with whether Medicare Part B would cover the surgery itself. That depends on both how Medicare characterizes the surgery -- "medical" or "dental" -- and on who performs it. If the doctor who performs your surgery is a medical physician (M.D.) rather than a dentist, Medicare Part B will almost certainly cover the care. If the dentist or oral surgeon who performs the surgery is not an M.D. physician, though, Medicare's decision about coverage would depend on the kind of treatment performed and the reasons for it. Medicare considers most work by non-physician oral surgeons as "dental" rather than "medical," and does not cover it. But Medicare Part B can cover non-physician treatment, which involves a problem with jaw or mouth bones or tissue, if it's the kind of treatment that physicians also perform. If so, the care might be considered "medical" and covered by Medicare Part B even if performed by a non-M.D. oral surgeon. So, if you can get your physician (not your dentist) to demonstrate to Medicare that the surgery is required because of your abscesses and other potentially serious medical problems, Medicare Part B might cover the cost of the surgery. Even if Medicare does decide to cover the surgery, however, the surgeon who performs it must participate in Medicare, and most dentists do not. So, your dentist might need to refer you to an oral surgeon who participates in Medicare.

In order to have Medicare Part A cover your hospitalization for the procedure, your doctor -- with the help of your dentist -- must convince Medicare that inpatient hospital care is medically necessary for you. That would mean providing Medicare with medical records and communications from the physician overseeing your overall care, and that doctor would probably need to be directly involved in having you admitted to the hospital.

All of this can and should be determined well in advance of your surgery. Your dentist and doctor together need to submit a request for coverage to Medicare. Medicare can then ask for whatever documentation it wants to see, and can provide you with a coverage decision before the surgery. The request from your doctor should include an explanation of why your hospitalization would be necessary due to your medical condition. All of this will take some time -- weeks and maybe months, depending on how quickly your dentist and doctor respond -- but prior approval from Medicare for both the surgery and the hospitalization might save you an enormous amount of money.