Why Does Medicare Exclude Dental Care at All? The 1965 Law, and the 2023 Rule That Finally Cracked It Open

Short answer: Medicare has excluded dental care since the program began in 1965, written into the founding statute as Social Security Act section 1862(a)(12), now codified at 42 USC 1395y(a)(12). The exclusion has never been repealed. What changed, starting in 2023, is that CMS began reading the same sixty-year-old statute more broadly through federal rulemaking, opening payment for dental work tied to specific covered medical treatments without Congress passing any new law.

That is the whole shape of the story: one exclusion, unchanged since 1965, and a widening set of regulatory exceptions built on language that was in the statute from the start.

What does the 1965 statute actually say?

The exclusion, in the exact words of the law, bars Medicare payment for services "in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth." That is the sentence dentistry has been read out of Medicare by for six decades. It draws a line between medical care and dental care as categories, and puts the second one outside the program's coverage, full stop, with one exception written into the same sentence.

The exception: payment may be made for inpatient hospital services connected to dental work if the patient, "because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services." That covers the hospital stay itself, when the patient's health or the procedure's severity makes hospitalization necessary. It was never a broad opening for dental coverage. It is why, for decades, Medicare dental coverage discussions began and ended with cases needing hospitalization.

Where does this fit in Medicare's history?

Medicare was created in 1965 as an amendment to the Social Security Act, and the dental exclusion was part of the law from that founding moment, not something added later. KFF's own summary of Medicare and dental coverage states it plainly: since its enactment in 1965, Medicare has not covered routine dental care. For most of Medicare's history, this was treated as close to absolute. If a claim was for dental work, the assumption on both sides, patient and biller, was that Medicare would not pay it, and for the overwhelming majority of dental work, that assumption remains correct today.

Year	What happened
1965	Medicare enacted; Social Security Act section 1862(a)(12) excludes dental care from coverage, with the inpatient hospitalization exception written in from the start
2023	CMS finalizes CMS-1770-F, the CY 2023 Physician Fee Schedule rule, codifying that dental services inextricably linked to a covered medical service are payable; effective January 1, 2023
2024	CY 2024 Physician Fee Schedule rule adds chemotherapy, CAR-T cell therapy, and high-dose bone-modifying drugs for cancer to the list
2025	CY 2025 Physician Fee Schedule rule adds dialysis for end-stage renal disease; KX modifier and diagnosis code become mandatory on these claims July 1, 2025

What actually changed in 2023, if the law did not?

CMS did not ask Congress to change the statute. It used the same language that had always been there, "in connection with the care, treatment, filling, removal, or replacement of teeth," and paired it with a companion idea that some dental services are inseparable from a covered medical procedure. The CY 2023 rule states this as a standard: dental services that are "inextricably linked to, and substantially related and integral to the clinical success of" a covered medical service fall outside the exclusion, because they are not being paid for as dental care. They are being paid for as a necessary part of medical care Medicare already covers.

That reasoning let CMS name specific scenarios, transplants, cardiac valve procedures, and, in the two rules that followed, cancer treatment and dialysis, as examples where the link is clear enough to pay. The list is regulatory guidance built on statutory language that has existed since 1965. It is not a new law, and it can be expanded or narrowed by future rulemaking the same way it was created, without needing an act of Congress.

Why did this take almost sixty years to happen?

The exclusion's plain text always allowed for the idea that some dental work is bound up with a covered medical treatment, since the hospitalization exception already recognized that severity of a dental procedure could require medical-grade care. What changed by 2023 was CMS's willingness to formalize a broader version of that same logic into an enforceable, coded standard that contractors could actually apply consistently, rather than deciding it case by case with no written rule. Before CMS-1770-F, a claim like this depended heavily on which contractor reviewed it and how it was coded. The 2023 rule gave the standard a name and a place in the regulation, at 42 CFR 411.15(i)(3), so the same claim would be judged the same way nationwide.

Could Congress ever add full dental coverage to Medicare?

Only Congress can repeal or rewrite section 1862(a)(12) itself, which is what full, routine dental coverage would require. Legislation to do exactly that has been introduced in past sessions of Congress. As of this writing, none of it has become law. Every expansion covered on this page, from 2023 through 2025, happened through CMS rulemaking under the existing statute, not through new legislation, which is an important distinction if you are trying to predict what Medicare might cover next: watch the annual Physician Fee Schedule rule, not a bill.

Does this history change how I should think about my own denial?

It should change one thing: what "Medicare doesn't cover dental" actually means when a front desk says it. It is true as a description of the 1965 exclusion and true for the overwhelming majority of dental work. It is not true for the specific, narrow, and still-expanding list of scenarios built on the same statute since 2023. If your dental work was connected to a transplant, cancer treatment, heart valve surgery, or dialysis, the exclusion that has stood since 1965 is not the rule that applies to your claim. A newer rule, resting on the same old law, is.

A note on who we are

CheckMyDenial helps patients read and appeal insurance denials. We are related to a company that does medical-dental billing and reimbursement for patients and practices, and if you ever move from reading to having someone handle a claim for you, that relationship and any fee are disclosed before anything is paid. This page is free, it does not require anything from you, and it will stay that way.

Where this comes from

The exact text of the 1965 exclusion and its inpatient hospitalization exception is drawn from 42 USC 1395y(a)(12), the current codification of Social Security Act section 1862(a)(12). The 1965 enactment date is confirmed by KFF's issue brief on Medicare and dental coverage. The 2023 rule and its inextricably-linked standard are drawn from the CMS fact sheet on the CY 2023 Physician Fee Schedule final rule, CMS-1770-F, and from 42 CFR 411.15(i)(3) itself. We looked for a documented 1980 exception separate from the original hospitalization language and could not verify one through a public source we could open, so we have not included that date. Links are listed at the end of this page. If you find something here that is out of date, tell us and we will fix it and change the date at the top.