Is Oral Surgery Covered Under Medicare?

Original Medicare Coverage for Oral Surgery

Medicare generally does not cover routine dental care. This includes most oral surgery procedures performed solely for the health of teeth, such as fillings, cleanings, or standard tooth extractions. Most beneficiaries pay 100% for these non-covered services.

Despite this general exclusion, Original Medicare (Parts A and B) provides limited coverage for oral surgery when medically necessary. Medicare Part A, covering inpatient hospital care, might cover the hospital stay if complex oral surgery requires admission due to an underlying medical condition or procedure severity.

Medicare Part B, covering outpatient medical services, may cover surgeon’s fees and diagnostic tests for medically necessary oral surgeries performed in an outpatient setting. This includes procedures related to covered medical treatments, such as an oral exam and dental treatment before a heart valve replacement, organ transplant, or radiation for jaw cancer. Coverage also extends to surgical repair of a jaw fracture or removal of a tumor affecting the jaw or mouth.

For covered services under Original Medicare, beneficiaries are responsible for certain cost-sharing amounts. In 2025, the Medicare Part A deductible for each benefit period is $1,676. After meeting this deductible, there are daily coinsurance payments for extended hospital stays, such as $419 per day for days 61-90 and $838 per day for lifetime reserve days.

For Part B services, the annual deductible in 2025 is $257. Once met, beneficiaries typically pay 20% of the Medicare-approved amount for most Part B-covered services, including medically necessary oral surgeries. Medicare pays the remaining 80%.

Medicare Advantage Plan Oral Surgery Benefits

Medicare Advantage Plans (Part C) offer an alternative way to receive Medicare benefits through private insurance companies. These plans must provide at least the same coverage as Original Medicare (Parts A and B), including medically necessary oral surgeries. Many also include additional benefits not covered by Original Medicare, such as dental, vision, and hearing services.

The scope of oral surgery and dental coverage varies significantly among different Medicare Advantage plans. Some plans may offer basic dental benefits, like routine cleanings, X-rays, and fillings, while others might provide more extensive coverage that includes certain oral surgeries and procedures like root canals, crowns, or even implants. This expanded coverage aims to address a broader range of dental health needs.

Beneficiaries considering a Medicare Advantage plan should carefully review the specific plan’s Evidence of Coverage document. This document details the exact dental benefits offered, including any limitations, exclusions, or cost-sharing requirements for oral surgery and other dental services. No universal standard for dental coverage exists across all Medicare Advantage plans.

For services covered by a Medicare Advantage plan, cost-sharing typically involves copayments, deductibles, and coinsurance amounts that differ from Original Medicare. These plans also have an annual out-of-pocket maximum, which limits how much a beneficiary has to pay for covered services in a year. In 2025, the maximum out-of-pocket limit for in-network services in Medicare Advantage plans can be up to $9,350.

Financial Considerations for Oral Surgery

Understanding the financial implications of oral surgery under Medicare involves recognizing various cost-sharing responsibilities. For medically necessary oral surgeries covered by Original Medicare, beneficiaries face deductibles and coinsurance. The 2025 Part A deductible is $1,676 per benefit period for hospital inpatient services, applying if a covered oral surgery requires an inpatient hospital stay.

For outpatient medically necessary oral surgeries covered by Medicare Part B, the 2025 annual deductible is $257. After meeting this deductible, beneficiaries are generally responsible for a 20% coinsurance of the Medicare-approved amount for the services. There is no annual out-of-pocket maximum with Original Medicare, meaning coinsurance costs can accumulate without a cap.

When oral surgery is covered by a Medicare Advantage plan, cost-sharing follows the specific plan’s structure. This often includes copayments for office visits or specific procedures, deductibles that must be met before the plan begins to pay, and coinsurance percentages. Unlike Original Medicare, all Medicare Advantage plans have an annual out-of-pocket maximum, which provides a cap on beneficiary spending for covered services.

When oral surgery is not covered by Medicare, such as routine dental procedures or those not medically necessary, the individual is responsible for the full cost. This can include common services like fillings, routine extractions not linked to a broader medical condition, or dentures. To manage these costs, some individuals opt for private dental insurance or dental discount plans.

Determining Your Specific Coverage

Confirming Medicare coverage for an oral surgery procedure requires proactive steps to avoid unexpected costs. First, consult your oral surgeon or dentist to understand the procedure’s nature and medical necessity. They can provide details on the medical coding, essential for determining potential Medicare coverage.

Next, directly contact Medicare if you have Original Medicare, or your specific Medicare Advantage plan provider if you are enrolled in Part C. Provide them with the precise medical codes and details obtained from your healthcare provider. Inquire about whether the procedure is covered, what portion Medicare or your plan will pay, and what your out-of-pocket responsibilities will be, including deductibles, copayments, or coinsurance.

For complex or costly procedures, it is advisable to seek pre-authorization from your Medicare Advantage plan, if required. Pre-authorization confirms coverage before the service is rendered, helping to prevent claim denials. It also provides an opportunity to understand any specific conditions or limitations of coverage.

Always obtain coverage details, including any pre-authorization approvals, in writing. This documentation can be a valuable reference if questions or discrepancies arise regarding billing or coverage after the procedure.