TN 3 (11-22)
As indicated under the general exclusions from coverage (see HI 00620.160) items and services in connection with the care, treatment, filling, removal, or
replacement of teeth or structures directly supporting the teeth are not covered.
For services before 7/1/81, payment may be made to a doctor of dental medicine or
dental surgery only for 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, including
dental splints or other appliances used for this purpose.
For services furnished after June 30, 1981 a dentist qualifies as a “physician” if the dentist is a doctor of dental surgery or of dental medicine who is legally
authorized to practice dentistry by the State in which the dentist performs such function
and who is acting within the scope of the dentists license when the dentist performs
such functions. Such services include any otherwise covered service that may legally
and alternatively be performed by doctors of medicine, osteopathy and dentistry, e.g.,
dental examinations to detect infections prior to certain surgical procedures, treatment
of oral infections and interpretations of diagnostic X-ray examinations in connection
with covered services. Because the general exclusion of payment for dental services
has not been withdrawn, payment for the services of dentists is also limited to those
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
If an otherwise noncovered procedure or service is performed by a dentist as incident
to and as an integral part of a covered procedure; or service performed by the dentist,
the total service performed by the dentist on such an occasion is covered.
The reconstruction of a ridge performed primarily to prepare the mouth for dentures
is a noncovered procedure. However, when reconstruction of a ridge is performed as
a result of and at the same time as the surgical removal of a tumor (for other than
dental purposes) the totality of surgical procedures would be a covered service.
Payment would be made for the wiring of teeth when this is done in connection with
the reduction of a jaw fracture.
The extraction of teeth to prepare the jaw for radiation treatments of neoplastic
diseases is also covered. This is an exception to the requirement that to be covered,
a noncovered procedure or service performed by a dentist must be an incident to and
an integral part of a covered procedure or service performed by the dentist.
When an excluded service is the primary procedure involved, it is not covered regardless
of its complexity or difficulty.
Payment can be made for a covered dental procedure no matter where the service is
Payment can also be made for services and supplies furnished incident to covered dental
services. For example, the services of a dental technician or nurse who is under the
direct supervision of the dentist or physician are covered if the services are included
in the dentist's or physician's bill.