CMS expands Medicare to cover medically necessary conditions requiring dental services

Final rule goes into effect Jan. 1

The Centers for Medicare & Medicaid released a final rule on Nov. 1 saying it will now cover dental services for Medicare beneficiaries under certain conditions deemed medically necessary. The expanded dental coverage will go into effect Jan. 1.

The ADA was pleased that CMS listened to many of the ADA's suggestions on the draft rule, which the Association shared in comments filed Sept. 2. In those comments the ADA told CMS it supported providing dental coverage for the following instances, all of which are included in the final rule:

• Reconstruction of a ridge when performed as a result of and at the same time as the surgical removal of a tumor.
• Stabilization or immobilization of teeth when done in connection with the reduction of a jaw fracture.
• Extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.
• Dental splints only when used in conjunction with medically necessary treatment of a medical condition.
• Dental services - including both examination and treatment - prior to cardiac valve replacement, valvuloplasty or organ transplant procedures.

The final rule stated that Medicare payment would be provided if these procedures were done on an outpatient or an inpatient basis. Coverage would also be provided for ancillary services such as X-rays, anesthesia, or the use of an operating room for medically necessary procedures that fall under the rule.

The final rule does not expand Medicare to cover dental services for patients with conditions such as diabetes. CMS said it will continue to evaluate the issues surrounding such a benefit. CMS is also delaying coverage for dental treatment prior to immunosuppressant therapy or joint replacement surgery. The agency also emphasized in the rule that the statutory definition of a physician, as well as the definition of a physician in the Medicare manual, includes dentists.

In the final rule, CMS said it will also be implementing an annual review process to assess whether to include additional services under the Medicare medically necessary dental benefit. The ADA will be involved in this process. The ADA will work with CMS to encourage the agency to provide guidance to dentists on enrollment, billing, compliance, and other administrative questions.

Read the ADA comments on the draft rule in full at ADA.org.

Follow all of the ADA's advocacy efforts at ADA.org/Advocacy.