Does Medicare Cover Oral Surgery Biopsy?

Medicare’s coverage of oral procedures can often seem complex, with many assuming dental care is not covered. While it is true that routine dental services typically fall outside Original Medicare’s scope, specific scenarios, particularly those involving medically necessary oral surgery biopsies, may qualify for coverage. This article explores the circumstances under which Medicare may cover oral surgery biopsies, offering clarity on this often-misunderstood area of health insurance.

Medicare’s Coverage of Oral Procedures

Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), generally does not cover routine dental care. This exclusion encompasses common services such as cleanings, fillings, dentures, or standard tooth extractions. For example, if a tooth needs to be pulled due to decay or for dentures, Original Medicare will not pay for it.

Specific exceptions exist where Medicare covers oral procedures. This usually applies when oral surgery is medically necessary for a covered medical condition or treatment. For example, procedures to repair a jaw after a fracture or to remove a tumor are often covered. Dental services performed in a hospital setting for an injury or illness can sometimes be covered by Medicare Part A.

Medicare Part A primarily covers inpatient hospital stays, which would include situations where medically necessary oral surgery requires a hospital admission. Medicare Part B covers outpatient medical services, including certain doctor’s services and diagnostic tests related to medically necessary oral conditions. While Medicare Advantage Plans (Part C) often offer additional dental benefits, these vary significantly by plan and are not standard benefits under Original Medicare.

Specific Coverage for Oral Surgery Biopsies

An oral surgery biopsy is generally covered by Medicare Part B when medically necessary to diagnose or treat a covered medical condition, as opposed to routine dental care. The procedure involves removing a small tissue sample from an oral lesion for diagnostic examination, typically to determine if it is benign or malignant. This distinction of medical necessity is central to Medicare’s coverage decisions.

Medically necessary situations that typically lead to coverage include biopsies performed to diagnose oral cancer or other serious medical conditions. This can involve investigating suspicious lesions, cysts, or tumors. For example, CPT code 40808, used for a biopsy of a mouth lesion, is reimbursed by Medicare and is listed on the Medicare Physician Fee Schedule. ICD-10 codes, such as K13.70 or K13.79, might be used for diagnostic purposes.

Biopsies required before or after specific medical treatments are also often covered. This includes procedures needed prior to organ transplants, heart valve replacement, or radiation treatment for certain conditions. Biopsies performed as part of routine dental check-ups or for cosmetic reasons would typically not be covered. The performing provider, such as an oral surgeon or physician, and the setting of care (outpatient clinic versus hospital) also influence whether coverage falls under Part B or Part A.

Navigating Coverage and Costs

Beneficiaries should communicate directly with their oral surgeon or medical provider’s office before a procedure to confirm coverage. It is advisable to ask for the specific CPT codes for the biopsy and the ICD-10 codes for the diagnosis. This information allows the provider to contact Medicare or your Medicare Advantage plan for pre-authorization or to confirm coverage based on medical necessity.

Contacting Medicare directly at 1-800-MEDICARE (1-800-633-4227) is recommended for an official determination. If you have a Medicare Advantage plan, contact your plan administrator directly, as their benefits and processes may differ from Original Medicare. Having your Medicare ID number and any relevant claim or plan information readily available will assist in these conversations.

Even if a procedure is covered, beneficiaries typically have out-of-pocket costs. For Medicare Part B services, after meeting the annual deductible ($257 in 2025), you are generally responsible for 20% of the Medicare-approved amount. For hospital inpatient stays covered by Part A, there is a deductible of $1,676 per benefit period in 2025.

Medigap policies (Medicare Supplement Insurance) can help cover these out-of-pocket costs, including deductibles and coinsurance. Medicare Advantage plans may also help reduce out-of-pocket expenses, but their cost-sharing structures, often involving fixed co-payments, vary significantly by plan.

Request an estimate of costs from the provider’s office prior to the procedure. Keeping detailed records of all communications, billing statements, and Explanation of Benefits (EOB) from Medicare or your plan is also recommended.