Older Adults Medicare Oral Surgery: Does Medicare pay for it?

Medicare will cover very few dental services, including medicare oral surgery.

Unfortunately, most routine dental care, procedures, or supplies are not covered by Medicare; however, some dental procedures like oral surgery are covered if you’re hospitalized or are deemed medically necessary.

While it’s crucial to practice good dental hygiene and care throughout your life, as you get older, it may become necessary to have oral surgery or other dental procedures to relieve pain, address problems, or even diagnose more serious medical conditions. A recent study by the National Institute of Dental and Craniofacial Research found that 25% of those aged 65 and up had put off their last dental visit for at least five years.

If you successfully qualify for Medicare, you may be able to get assistance with the expense of dental work or medicare oral surgery. You can determine how much you will have to pay out of pocket by knowing what is and is not covered. There are some exclusions and exceptions to be aware of.

Do they cover oral surgery under Medicare?

Medicare might pay for oral surgery if it is deemed medically necessary and is carried out by a physician or surgeon who accepts Medicare.

Examples of oral surgery that may be covered include:

• A component of a treatment regimen for conditions like cancer or heart disease (biopsy).
• One element of a procedure covered is reconstructing your jaw after an accident.
• Oral examinations before a kidney or heart valve transplant.
• Extract teeth before receiving radiation treatments.
• Reconstruction of the jaw following tumor removal.
• Surgery, including the use of dental splints or wiring, to treat facial or jaw fractures.

Medicare Part A or Part B would pay for the oral surgery in these situations.

Part A Coverage: If you are a hospital inpatient who needs an emergency or dental procedure, and a hospital-employed, Medicare-approved dentist carries out the procedure, the procedure is probably covered. When you receive treatment in:

• Acute care facility
• A critical access facility
• Hospital-based rehabilitation center
• Long-term care facility
• Hospitalization as a required component of a research study
• Care for mental health

If you need to be hospitalized for dental reasons, Medicare will pay for expenses like lodging, food, anesthesia, and x-rays. Dentures and other dental services not covered by Original Medicare are still not covered.

Part B Coverage: If a doctor carries out oral surgery and satisfies specific requirements, Medicare may pay for it. Outpatient diagnostic tests, services, and exams needed for a kidney transplant or heart valve replacement may also be covered.

Any authorized drugs prescribed to you before or after a dental procedure would also be covered by Medicare Part D drug coverage.

Check with your provider, Medicare, your Medicare Advantage plan, or your dental plan to ensure your dental procedure or oral surgery is covered before the procedure to avoid being charged and having to pay out-of-pocket. Find out from your surgeon whether they accept Medicare and if they can provide an estimate of the cost of the procedure and your out-of-pocket expenses.

What is oral surgery?

As you age, you run a higher risk of developing conditions like gum disease and oral cancer. Usually, if your regular dentist discovers a problem that necessitates oral surgery, they will refer you to a specialist or oral surgeon. This surgeon can perform biopsies, dental implants, jaw surgery, and tooth extraction if required.

Dental procedures for problems affecting your teeth, gums, jaw, and even facial bones can be considered oral surgery. You might require the services of an oral surgeon in the following three situations:

• Tooth Extraction: A referral to an oral surgeon may be necessary for difficult extractions or the removal of wisdom teeth, even though your general dentist can usually conduct tooth extractions (or tooth removals).
• Corrective surgery: In order to recover effectively from facial or jaw fractures caused by accident, you might need dental splints or wire. An oral surgeon can be of use here.
• Restorative Surgery: An oral surgeon can remove tumors from the mouth or face and then repair or reconstruct the affected area.

Does Medicare cover dental extractions and implants?

Medicare typically won’t pay for tooth extractions unless a Medicare-approved oral surgeon deems them medically necessary. Removal of teeth, infected teeth in an infected jaw or preparation for dentures are not covered either.

Original Medicare may pay for the extraction of a tooth if you have a disease of the jaw that necessitates one.

Note: Dental extractions are a common procedure that your Medicare Advantage plan may cover if you have routine dental coverage.

Does Medicare cover gum surgery?

Unless it is medically necessary by an oral surgeon who Medicare has approved, Medicare typically does not cover gum surgery.

Some types of gum disease, like gingivitis or periodontitis, may sometimes need surgery to treat (an infection that softens the tissue that holds your teeth in place). Your dentist may advise surgery to help remove the disease and restore the health of your gums, depending on how severe or advanced the infection or disease is.

Gum surgery is typically not included in a covered procedure or treatment plan.

Does Medicare cover the removal of wisdom teeth?

Medicare typically does not pay for the removal of wisdom teeth (unless the procedure is deemed medically necessary by an oral surgeon who Medicare has approved).

The final teeth to erupt and the ones located furthest back in your mouth are wisdom teeth. Problems can arise when wisdom teeth grow at an unusual angle and become impacted or stuck. Sometimes wisdom teeth do not develop or erupt at all. Wisdom teeth may need to be removed if they cause issues like pain. Other teeth may also be moved or damaged as a result of them.

Wisdom teeth typically erupt between the ages of 17 and 25. After that, you probably won’t experience problems or pain again.

How much does Medicare cover for oral surgery?

To receive oral surgery covered by Medicare Part A, you must first satisfy the Part A deductible, which in 2022 is $1,566. Additionally, you must pay the $233 annual Part B deductible (in 2022).

You typically pay an additional 20% of the surgery’s or procedure’s Medicare-approved cost once your deductibles are met or if you’ve met them before the surgery. Medicare will pay for the remaining 80%.

Make sure a Medicare-approved, participating provider is performing your oral surgery. This indicates that the service provider has consented to accept the Medicare-approved sum in exchange for their services. You could be required to pay more out-of-pocket, possibly up to 100 percent of the cost, if you choose not to have surgery from an approved, participating provider.

Your particular out-of-pocket expense for an approved procedure may vary. This primarily depends on the nature of the specific procedure and whether you will need prescription medication after the procedure.

What kind of dental care does Medicare not cover?

Dental treatment and oral surgeries are done primarily for tooth health and are not covered by Original Medicare Parts A and B. These services are not covered:

• Oral tests
• Cleanings
• Fillings
• Extractions of teeth (in some cases)
• Dentures
• X-rays
• A root canal
• Dental guards
• Other dental appliances, such as bridges, implants, and crowns

Oral surgery performed to treat teeth, such as placing bridges, crowns, or dentures, is not covered by Medicare. If you don’t have Part C coverage or additional dental insurance, you’ll have to pay the full cost of any uninsured services.

It’s crucial to remember that even if your oral surgery or dental procedure is covered, Medicare probably won’t pay for any additional dental care required after the initial treatment for the health condition.

Do Medicare Advantage plans cover oral surgeries?

Conditions like cancer or heart disease (biopsy) may need oral surgery to be treated. This kind of oral surgery may be necessary for medical reasons in certain situations.

The following are some situations in which Medicare may cover oral surgery:

• When it is medically necessary to remove a damaged or infected tooth before starting radiation therapy
• Medicare will pay for the procedure if you need surgery for a fractured jaw.
• Medicare will cover the cost of the procedure if your jaw needs to be repaired or restored after the tumor has been removed.

Because every situation is different, you should speak with your doctor or review the specific requirements of your plan.

Part A of Medicare.

You might qualify for coverage under Medicare Part A if you are admitted to a hospital as an inpatient and know that you will need oral surgery to treat a medical condition.

Part B of Medicare.

It is a health insurance program that covers hospital stays and medical costs.

If you need outpatient oral surgery, Medicare Part B might be able to pay for it.

Part C of Medicare.

The best option for you might be a Medicare Advantage plan (Medicare Part C) that pays for routine dental procedures. Especially if you anticipate soon needing oral surgery for dental health issues.

Conversely, dental services are not a part of any Medicare Advantage plan.

Part D of Medicare (Medicare Prescription Drug Plan).

Unless administered intravenously, necessary medications such as those required to treat infection or pain will be covered by Medicare Part D.

Part B will pay for the costs of administration and prescriptions of treatment if you are given medications intravenously in a hospital setting. Most Medicare Advantage plans also cover the cost of prescription drugs.

Medical Supplement Insurance (Medigap)

Under certain conditions, Medigap might be able to pay for your Part A deductible and coinsurance costs if you need medically necessary oral surgery in a hospital setting. Medigap does not cover costs associated with dental procedures performed on the mouth.

Can I purchase a dental plan on its own?

Yes, you can buy a standalone, separate dental plan to pay for services that Original Medicare does not cover. Private insurance providers typically offer dental insurance, but their premiums can be high. If you’re thinking about getting a separate dental plan, make sure it covers:

• Emergency, diagnostic, and preventive services.
• Basic dental restorative care (fillings, root canal, periodontal treatment, etc.)
• Comprehensive dental care (crowns, bridges, dentures, etc.)

In most cases, these plans won’t fully cover these services, but they can lessen the financial burden of paying for them out of pocket. Additionally, consider that not all dentists participate in every insurance plan, so consult your dentist or oral surgeon before choosing.

What are your out-of-pocket costs for medicare oral surgery?

You are responsible for all associated expenditures if you have oral surgery that is not medically required.

You might still be required to cover some costs even if your oral surgery is medically necessary. An example would be

Copays: If a Medicare-qualified physician performs the procedure and the Medicare program approves it, the Medicare program will cover up to 80% of the cost of medically necessary oral surgery. If your operation is done in a hospital and you don’t have additional Medigap insurance, the cost will be 20% of the overall cost.

Deductible: Medicare Part B typically imposes a $203 annual deductible that must be met before the insurance company will pay for many services, including medically necessary oral surgery.

Monthly cost: The federal government sets the monthly premium rate for Medicare Part B at $148.50. Depending on your current income, the cost of this may be lower or higher for you if you currently receive social security benefits.

Medication: You must have Medicare Part D or another type of drug coverage to have all or a portion of the cost of your medications covered by Medicare Part D or another type of drug coverage. If you don’t have prescription drug coverage, you’ll have to pay for any medicines the doctor gives you.

The final verdict is as follows:

Basic dental care or oral surgery is done merely to maintain dental health are not covered by Medicare Part A. Some Medicare Advantage plans may cover oral surgery required to maintain the health of your teeth or gums.

Original Medicare may cover the cost of your oral surgery if it is medically necessary. You might still be required to cover out-of-pocket costs.

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