CMS Proposes Changes to Medicare Reimbursement for Dental Services

Building on recent changes, the Centers for Medicare and Medicaid Services' (CMS) proposed Physician Fee Schedule (CY 2025) recommends new additions to, “clinical scenarios under which FFS payment may be made for dental services.” Historically, Medicare has been unable to pay for most dental services. Dating back to the original 1965 law, Medicare only covers services under certain limited circumstances, and in most cases, it does not cover routine services such as cleanings, fillings, or dentures. However, some exceptions do apply, specifically in the case of “medically necessary” dental services, and in 2023, CMS began to clarify its interpretation of statute, codify payment policies, and define scenarios where dental services are covered. CMS expanded on its work in 2024, and the 2025 fee schedule is continuing to this process.

What exactly is new?

The specific amendment, to 42 CFR § 411.15(i)(3), adds coverage for oral examination prior to Medicare covered dialysis services, as well as diagnostic and treatment services to eliminate oral infection for those same patients. Dental issues and kidney disease are linked, and kidney disease can increase the risk of complications from infections. Furthermore, CMS is seeking public comment on including dental services for individuals with several other conditions: diabetes, autoimmune diseases, sickle cell disease, and hemophilia. This amendment builds on existing coverage for dental services related to cancer, treatment for jaw injuries, and various transplantation and cardiac procedures.

Why does this change matter?

CMS says that exploring means of expanding access to dental services, within the bounds of existing law, is part of its commitment to whole-person care. Trends in healthcare policy have begun to emphasize the many interlocking aspects of health, and emphasis on preventative care, particularly care that is cost-saving, will continue to drive coverage decisions. That being said, expanding to more extensive dental coverage under Medicare would require federal legislation.

In the meantime, policy innovations using existing law are laudable. Dental health has long been linked to major health conditions including heart disease and diabetes. Endocarditis has been linked to gum disease, and routine preventative care and regular brushing reduce the risk of heart disease. Overall healthcare costs for patients with diabetes have been linked to periodontal care, with patients with commercial insurance showing a 12% reduction in overall costs compared with those who did not receive treatment.