Does Medicare Cover Oral Surgery?
Yes, Medicare does cover oral surgery so long as it is a medical necessity. Medically necessary procedures are:
- Prescribed by a doctor as essential in diagnosing, treating, curing, or relieving a health condition, illness, injury, or disease.
- Not for experimental, investigational, or cosmetic purposes.
- Within the generally accepted standards of medical care.
Oral surgery involves artificial modification of the teeth, jaw, or gums. While Medicare makes occasional exceptions for medically necessary or emergency surgery, it will not cover routine dental care like fillings or cleanings. For basic dental coverage, Medicare members can purchase standalone benefits or seek assistance through HRSA programs.
Table of Contents
What Is Oral Surgery?
Oral surgery refers to any operation on the teeth, gums, jaw, or surrounding area needed to restore dental and physical health. Conditions requiring oral surgery include:
- Extreme tooth decay
- Broken or impacted teeth
- Gum disease
- Jaw disorders
- Sleep apnea
- Oral cancer
- Severe facial injuries
Of all oral surgeries, extractions to remove broken, diseased, or impacted teeth occur most frequently. However, doctors may also recommend bone or gum grafts to treat decay, implants to replace missing roots, or corrective jaw surgery to address chewing issues and facial misalignment. Unfortunately, without proper medical precedent, Medicare will classify these procedures as routine dental care and withhold member benefits.
Understanding Medicare Coverage For Oral Surgery
Medicare oral surgery coverage depends on your eligibility and the type of benefits you receive through the program.
To qualify for Medicare benefits, a doctor must prescribe oral surgery as a medically necessary component of a treatment plan for a primary health issue. Examples of oral surgery covered by Medicare include:
- Extraction of a damaged or diseased tooth preceding cancer radiation treatment
- Oral examinations and teeth extractions preceding a heart valve replacement or kidney transplant.
- Reconstructive jaw surgery following the removal of a facial tumor.
- Surgical repair of a jaw fracture or other debilitating facial injury.
Remember that your coverage eligibility ultimately depends on your Medicare plan and doctor’s treatment strategy. Ensure to discuss options with your medical provider and review your policy details before scheduling surgery.
Part A Coverage
Medicare Part A helps cover hospital inpatient, nursing, hospice, and home health care. In the context of oral surgery, Part A will cover Part of any medically necessary procedure that requires an inpatient hospital stay, such as reconstructive or emergency surgery. Specifically, Part A would cover your semi-private room, meals, general nursing care, drugs administered on hospital grounds, and any other supplies required to address your condition.
Patients who meet Medicare Part A eligibility for oral surgery must pay their $1600 annual deductible before receiving covered services. Part A will cover the first two months of a hospital stay free of charge and begin levying sizeable coinsurance fees every day thereafter.
Part B Coverage
Medicare Part B covers outpatient care like doctor’s services, diagnostic tests, preventative care, and surgery. Part B will also cover anesthesia and take-home durable medical equipment like wheelchairs, crutches, and nebulizers. Since most minor oral surgeries do not require inpatient hospital stays, they typically see coverage through Part B.
Medicare Part B will pay 80% of qualified expenses for medically necessary oral surgeries, leaving members with a 20% coinsurance and their $226 Part B deductible. For example, if your outpatient tooth extraction cost $180 and you had already met your yearly deductible, you would only owe $36 for the service.
Part D Coverage
Medicare Part D is an optional coverage that helps cover some medication costs. Following oral surgery, patients with Part D can use it to pay for prescribed take-home pharmaceuticals and antibiotics necessary to treat pain or infection. Private companies fund Part D plans and impose independent drug formularies and cost-sharing strategies, so check with your insurance provider before receiving care.
Medicare Supplement, or Medigap, fills in “gaps” in your Original Medicare coverage. For example, if Medicare Part B covered 80% of a medically necessary oral surgery, your Medigap plan would pay some or all of your 20% coinsurance. Each of the ten existing Medigap plan types absorbs 50–100% of your Medicare coinsurance, while some will even pay your deductible. Keep in mind that some Medigap plans have a deductible and may not pay any of the coinsurance.
How Does Medicare Advantage Cover Oral Surgery?
By law, Medicare Advantage plans provided by private companies must offer all the same benefits as Original Medicare Part A and Part B. Therefore, MA policies must cover qualified oral surgery at least identically to Original Medicare. Unlike Original Medicare, however, Medicare Advantage plans often expand coverage to include prescription drugs and routine dental care.
Medicare Advantage coverage of oral surgery depends on your specific plan and location. Because private entities fund and govern these policies, they set independent rules around cost-sharing and benefit distribution. Sometimes, MA providers may even inhibit your healthcare options to doctors within a preapproved medical network.
How Much Does Oral Surgery Cost With Medicare?
Out-of-pocket costs affiliated with Medicare-covered oral surgery typically include:
- Coinsurance: Medicare Part B will cover 80% of all eligible doctor’s services required for oral surgery, leaving patients to pay the remaining 20%.
- Deductible: All Medicare members must meet their annual deductibles before receiving covered care. In 2023, the Part A and Part B deductibles are $1600 and $226, respectively.
- Medication costs: Oral surgery typically requires a post-op pharmaceutical regimen to prevent infection and manage pain.
Final surgery costs will vary widely depending on the type of operation you require, where you receive it, and your coverage details. Below is a loose out-of-pocket estimate for an average oral surgery with baseline Original Medicare coverage:
Medication #1 (Pain Relief)
$266 (without Part D)
$110 (without Part D)
Additional Cost #1(Anesthesia)
$180 (20% coinsurance)
Additional Cost #2(Dentures)
$1230 (“secondary service” uncovered by Medicare)
Alternatives To Medicare Covered Oral Surgery
Those unable to access Oral Surgery procedures can explore alternative routes to discount oral surgery. For instance, many state Medicaid programs offer dental benefits to individuals with limited resources. Likewise, students at certified dental schools and hygiene training facilities can provide low-cost oral surgery as Part of their education. Or, if your spouse has dental coverage from their employer, you can opt into their plan or purchase standalone dental benefits independently.
Nearly 1,400 health centers provide affordable, accessible, high-quality medical, dental, and mental healthcare to underserved communities nationwide. Interested parties can call the toll-free hotline at 1-800-275-4772 to inquire about free or low-cost oral surgery.
Pre-approval For Oral Surgery
Though Original Medicare rarely necessitates prior authorization for qualified healthcare services, Medicare Advantage and Part D plans often require patients to secure preapproval for oral surgery. These individuals must follow the steps below to guarantee benefits:
- Refer to your plan documents and drug formulary: You can find information about covered medications and services that require pre-approval on your insurer’s website.
- Give your medical provider all relevant information for submission: Your doctors must officially request pre-approval on your behalf and prove that oral surgery qualifies as a medical necessity.
- Receive permission and schedule surgery: Medicare will grant you pre-authorization for surgery and any prescribed medications within a week. If the request gets denied, your medical provider can file for an exception.
Can Medicare Deny Your Claim?
Typically, Original Medicare will not cover dental care. Though exceptions may occur for medically necessary oral surgery, these claims often get denied if they do not meet Medicare eligibility. For example, Medicare will not pay for a tooth extraction unrelated to a more significant health problem.
Some claims get denied simply due to improper filing or information errors. If so, you must contact your medical provider and ask them to correct and resubmit the relevant forms. However, in the case of an eligibility judgment, you must file for a Medicare appeal. Your quarterly Medicare Summary Notice (MSN) will explain any claims denials and how and when to appeal them.
Can a Health Savings Account (HSA) Be Used for Oral Surgery Costs Not Covered by Medicare?
Yes, you can use funds in your HSA to pay for oral surgery costs. Health savings accounts (HSAs) allow members to contribute pretax dollars for deferred use on eligible medical and dental expenses. To distribute these tax-advantaged funds, the IRS simply requires that withdrawals get put toward the “alleviation or prevention of a physical or mental disability or illness.”
If you qualify for Medicare-covered oral surgery, you can pay your deductible and coinsurance using HSA distributions. If not, you can use your HSA to pay the entirety of the uncovered surgery bill. HSAs cover wisdom tooth removal, tissue and bone grafts, extractions, full-mouth reconstructions, and many other forms of oral surgery. You can even access your HSA to pay your travel expenses to a qualified medical center.
Are Oral Surgery Costs Covered If I’m Enrolled in a Medicare Trial Program?
Yes, depending on your policy and condition. Seniors interested in Medicare Advantage can enroll in 12-month policy trials before fully committing to benefits. Suppose a Medicare Advantage policy does not suit your needs or budget. In that case, you can switch back to Original Medicare and purchase Medigap or Medicare Part D within the trial window without undergoing repeat medical underwriting.
Trial benefits should fully match those of a tentative long-term Medicare Advantage plan. Because these policies often include dental benefits, oral surgery has a higher likelihood of coverage than it would under Original Medicare. Even so, medically necessary surgeries should always qualify for coverage, even during a trial program.
Does Medicare Cover Anesthesia for Oral Surgery?
Yes, Medicare will cover anesthesia for medically necessary oral surgery. Though some dental procedures only require local numbing anesthetics, most serious oral surgeries utilize intravenous or general anesthesia to “put a patient to sleep.” Surgeries of this magnitude include impacted wisdom tooth removal, jaw reconstruction, dental implant placement, and any other procedure involving prolonged and painful incisions to the facial area.
On average, sedation anesthesia costs about $700 for the first hour and another $170 every 15 minutes afterward. Therefore, final expenses vary widely depending on the length of your procedure. Regardless, Medicare Part B would cover 80% of all medically necessary anesthesia.
Putting It All Together
While Original Medicare rarely covers routine dental care, it does make exceptions for medically necessary oral surgeries. These typically must precede other vital procedures, such as tooth extraction before cancer radiation treatment or a heart valve replacement. Depending on the situation, severe jaw fractures resulting from accidents can also qualify for Medicare-covered reconstructive surgery.
Even with Medicare coverage, the high cost of anesthesia and necessary post-op prescription medications can extend beyond many people’s budgets. Lower-income beneficiaries can explore alternative treatment routes, such as discounted dental school care, Medicaid, or non-profit BPHC services nationwide. If you have persisting jaw or teeth issues, call your Medicare agent to discuss your options and determine the best course of action.