As a general rule, Medicare does not cover dental services, except in limited circumstances. In the past, for patients undergoing radiation therapy, this meant that dental services such as extractions or oral surgery were not covered, placing a significant financial burden on patients already facing a complex medical condition. However, in the 2023 Medicare Physician Fee Schedule (MPFS) final rule, the Centers for Medicare and Medicaid Services (CMS) clarified that Medicare payment under Parts A and B can be made when dental services are furnished in either the inpatient or outpatient setting when the dental services are inextricably linked to, and substantially related and integral to the clinical success of, other covered services.1 The rationale is that, “Some dental services are so integral to other medically necessary services that the clinical success of the service is dependent upon or inextricably linked to the dental services.”
In the 2024 MPFS final rule, CMS codified that payment can be made for dental services that are inextricably linked to head and neck cancer treatments, including services before and during treatment, and services to address dental complications following treatment. CMS continues to accept public comments on other clinical scenarios that may involve dental services that are inextricably linked to other covered services.
Impact on head and neck cancer patients
Radiation therapy for head and neck cancers often leads to severe oral complications, including dry mouth, mucositis and osteoradionecrosis. These conditions can significantly impair a patient’s ability to eat, speak and swallow, impacting overall quality of life. Adequate dental care before, during and after radiation therapy plays an important role in preventing and managing these complications. Under the new policy, Medicare will cover dental services that are medically necessary for patients undergoing covered treatments,2 including:
- Dental or oral exams as part of a comprehensive workup prior to treatment for head and neck cancer
- Dental services to eliminate an infection prior to or contemporaneously with head and neck cancer treatment
- Medically necessary diagnostic and treatment services to address dental or oral complications after head and neck cancer treatment using radiation, chemotherapy, surgery or any combination of these
Care coordination essential
Care coordination between the radiation oncologist and dentist must be documented in the medical record. Without this documentation, there is no evidence supporting the inextricable link between the covered medical service and the dental services, and Medicare will not pay for the dental services. A referral or exchange of information between the physician and the dentist is sufficient to meet this requirement.
The expansion of Medicare coverage for dental services is a significant step toward improving the care of patients with head and neck cancers. By understanding the details of the new policy and working collaboratively with dental providers, radiation oncologists can help ensure that their patients receive the oral health care they need.
For more details, including information on how to submit a claim, see the CMS Oral Health Cross Cutting Initiative Fact Sheet and the Medicare Dental Coverage page.
1) See 42 U.S.C. § 1395y and 42 CFR § 411.15(i)
2) This list includes examples only; Medicare administrative contractors (MACs) retain discretion to determine on a claim-by-claim basis whether a patient’s circumstances do or do not fit within the terms of the preclusion or exceptions specified in 42 U.S.C. §1395y and 42 CFR § 411.15(i)
