> ## Documentation Index
> Fetch the complete documentation index at: https://dso.getlemma.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Medicare and dental

> Why traditional Medicare pays almost nothing for dental: the § 1862(a)(12) exclusion, the 42 C.F.R. § 411.15(i)(3) inextricably-linked scenarios, DMEPOS for sleep appliances, and who should enroll.

**Traditional Medicare begins with a statutory dental exclusion.** A dental group may still encounter Medicare fee-for-service through covered medically linked services, DMEPOS billing for sleep appliances, and certain oral-surgery or institutional pathways. Many routine dental benefits associated with Medicare instead come from [Medicare Advantage supplemental benefits](/reference/payers/profiles/medicare-advantage-dental).

Payer portals, forms, IDs, and procedures change frequently. **Timely-filing limits and other participation terms come from the applicable current payer materials and your executed agreement.** Use this page as a starting point, then verify the product, entity, provider, location, and effective date with the payer.

## The exclusion

**Social Security Act § 1862(a)(12)** (42 U.S.C. § 1395y(a)(12)) bars Medicare payment “for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” The statute separately permits payment for inpatient hospital services when the patient's condition or the severity of the dental procedure requires hospitalization. That exception covers the qualifying hospital services rather than automatically covering the dental procedure itself.<sup>1</sup>

## The "inextricably linked" scenarios; 42 C.F.R. § 411.15(i)(3)

In the CY 2023 Physician Fee Schedule final rule, CMS explained when Parts A and B may pay for dental services that are **“inextricably linked to, and substantially related and integral to the clinical success of,” other covered medical services**. CMS reasoned that qualifying services fall outside the exclusion as applied in those circumstances.<sup>2</sup>

| Scenario                                                                                                                                                   | Effective                                                                                                                                                                     |
| ---------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| Dental exams and medically necessary treatment (e.g., eliminating oral infection) **before organ transplant, cardiac valve replacement, or valvuloplasty** | CY 2023                                                                                                                                                                       |
| The same **before treatment of head and neck cancers**                                                                                                     | CY 2024                                                                                                                                                                       |
| Additional analogous scenarios                                                                                                                             | Added through an **annual public-submission process** in each PFS rule. Check [CMS's dental coverage page](https://www.cms.gov/medicare/coverage/dental) for the current list |

This is a narrow carve-in, not a dental benefit: routine dental in traditional Medicare remains excluded.

## DMEPOS: sleep appliances

Custom oral appliances for obstructive sleep apnea (HCPCS `E0486`) are **durable medical equipment under Medicare**, payable with a sleep-study-documented OSA diagnosis and a physician order, but billing them requires **Medicare DMEPOS enrollment**, which is separate from ordinary Part B enrollment and carries a three-year revalidation cycle. This is medical crossover billing on the 837P/CMS-1500 with CPT/HCPCS and ICD-10 codes, not CDT on the 837D. See [Bill medical for dental work](/guides/billing/bill-medical-for-dental-work).<sup>3</sup>

## Who should enroll

| Situation                                                                                 | Medicare posture                                                                                                                |
| ----------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------- |
| General dentistry, hygiene, restorative                                                   | **No enrollment needed**; the book is commercial, Medicaid, and patient-pay                                                     |
| Dental sleep medicine (OSA appliances)                                                    | **DMEPOS enrollment**                                                                                                           |
| Oral surgery with medical indications; hospital-based dentistry; § 411.15(i)(3) scenarios | Part B enrollment via [PECOS](https://pecos.cms.hhs.gov/). See [Enroll in Medicare](/guides/enrollment/enroll-in-medicare)      |
| Seeing Medicare patients without billing Medicare                                         | Consider ordering/referring or opt-out status with counsel. Do not simply ignore the question if you touch the linked scenarios |

## Operational notes

* **Medicare Advantage dental follows the plan's supplemental benefit.** It is administered through the plan's dental network and does not use the same coverage pathway as fee-for-service Medicare. See [Medicare Advantage dental](/reference/payers/profiles/medicare-advantage-dental).
* **CMS revisits covered medically linked scenarios through rulemaking.** Check the current Physician Fee Schedule materials before writing off or billing a medically linked service.

## Sources

1. SSA § 1862(a)(12), [statute text](https://www.ssa.gov/OP_Home/ssact/title18/1862.htm); CMS, [Medicare dental coverage](https://www.cms.gov/medicare/coverage/dental).
2. CY 2023 Medicare Physician Fee Schedule final rule (87 FR 69404; dental discussion at 87 FR 69663–69688), [fact sheet](https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-final-rule); CY 2024 extension, [fact sheet](https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-proposed-rule).
3. Dental sleep medicine billing overviews: [Nierman Practice Management](https://niermanpm.com/blog/medical-billing-for-dentists-sleep-apnea/); [Glidewell](https://glidewelldental.com/company/blog/how-to-bill-medical-insurance-for-dental-sleep-medicine-cases).