A dentist is a “physician” under the health insurance program if he is a doctor of dental surgery or dental
medicine legally authorized to practice dentistry by the State in which he performs
his services. However, a dentist is a physician only with respect to surgery related
to the jaw or any structure contiguous to the jaw, or the reduction of any fracture
of the jaw or any facial bone. In general, “the jaw or any structure contiguous to the jaw” includes structures of the facial area below the eyes; e.g., mandible, teeth, gums,
tongue, palate, salivary glands, sinuses, etc.
Because of the general exclusion of payment for dental services, payment for the services
of dentists is also limited to those surgical procedures which are not primarily provided
for the care, treatment, removal, or replacement of teeth or structures directly supporting
teeth. The coverage or exclusion of any given dental service is not affected by the
professional designation of the “physician” rendering the service; i.e., an excluded dental service remains excluded and a covered
dental service is still covered whether furnished by a dentist or a doctor of medicine.
Effective with admissions on or after 1/1/73, the 1972 Amendments authorize the dentist
caring for the patient to certify (without corroborating certification by a physician)
that because of the patient's underlying medical condition and clinical status, he
requires hospitalization for performance of excluded dental procedures.