HI 00610.290 Dental Services

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 he is a doctor of dental surgery or of dental medicine who is legally authorized to practice dentistry by the State in which he performs such function and who is acting within the scope of his license when he 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 Because the general exclusion of payment for dental services has not been withdrawn, payment for the services of dentists is also limited to those procedures which are not primarily provided for the care, treatment, removal, or replacement of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 or osteopathy.

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 him, the total service performed by the dentist on such an occasion is covered.

Example:

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 him.

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 performed.

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.


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http://policy.ssa.gov/poms.nsf/lnx/0600610290
HI 00610.290 - Dental Services - 09/15/1989
Batch run: 01/27/2009
Rev:09/15/1989