CMS Is Quietly Expanding Medicare Dental Coverage: What Changed

Since 2023, the Centers for Medicare and Medicaid Services (CMS) has been quietly expanding the dental services that Original Medicare covers. While these changes have not received widespread attention, they represent a meaningful shift in how Medicare handles dental care. For the first time, Medicare is covering dental treatment for beneficiaries with certain medical conditions, under the principle that dental care can be integral to the treatment of those conditions.

This article explains what CMS has changed, which medical conditions now trigger dental coverage, how the KX modifier works, and what these changes mean for Medicare beneficiaries. These expansions do not replace the need for dental insurance, but they do provide important coverage for beneficiaries facing serious health conditions.

The Integral to Treatment Framework

Original Medicare has always excluded routine dental care such as cleanings, fillings, extractions, and dentures. The Medicare statute specifically states that payment may not be made for dental services or services in connection with the care, treatment, filling, removal, or replacement of teeth. For decades, this exclusion was interpreted broadly, leaving dental care almost entirely outside of Medicare's scope.

CMS has reinterpreted this language through annual rulemaking. The agency now takes the position that when dental services are integral to the treatment of a covered medical condition, those dental services can be covered under Medicare Part A or Part B. This does not mean routine dental care is covered. It means that when a dental problem could interfere with the treatment of a serious medical condition, Medicare can pay for the dental care needed to proceed with that treatment.

This framework is sometimes called the integral to treatment standard. It allows CMS to add new medical conditions to the list of triggers for dental coverage each year through the Physician Fee Schedule final rule, without needing legislation from Congress.

2023 Expansion: Organ Transplant Dental Coverage

The first major expansion came in the 2023 Physician Fee Schedule final rule. CMS established that dental exams and necessary dental treatment before organ transplant surgery would be covered by Medicare. The medical rationale is straightforward: dental infections can cause serious complications after organ transplant because the patient's immune system is suppressed by anti-rejection medications.

Transplant teams have long required patients to have a dental evaluation and clearance before being placed on the transplant waiting list. Before the 2023 rule, patients had to pay for this dental work out of pocket or find other coverage. Now, Medicare covers the dental exam and any necessary treatment to clear a patient for transplant surgery.

This was a significant step because it established the legal and policy framework for future expansions. CMS demonstrated that it could use existing statutory authority to cover dental services under specific medical circumstances without new legislation.

2024 Expansion: Cancer Treatment and Cardiac Valve Procedures

In the 2024 Physician Fee Schedule final rule, CMS added two more categories of medical conditions to the dental coverage framework. First, dental exams and treatment before certain cancer treatments were added. Chemotherapy, radiation to the head and neck, and other cancer therapies can cause severe oral health complications. Addressing dental problems before starting these treatments reduces the risk of infections, complications, and treatment delays.

Second, CMS added dental coverage for patients undergoing cardiac valve replacement or repair procedures. Dental infections, particularly periodontal disease, are a known risk factor for infective endocarditis, a serious and potentially life-threatening infection of the heart valves. Dental clearance before cardiac valve procedures helps reduce this risk.

Both additions followed the same integral to treatment logic established in 2023. The dental care is not routine maintenance but rather treatment necessary to safely proceed with the medical procedure. Medicare covers the dental evaluation and any medically necessary dental treatment directly related to preparing for the cancer therapy or cardiac procedure.

2025 Expansion: ESRD Dental Coverage and the KX Modifier

The 2025 Physician Fee Schedule final rule brought two important changes. First, CMS added dental coverage for Medicare beneficiaries with end-stage renal disease (ESRD) who are undergoing dialysis. Research has shown that poor oral health can worsen outcomes for dialysis patients, increase infection risk, and complicate management of the underlying kidney condition. Medicare now covers dental exams and treatment before and during dialysis.

Approximately 800,000 Americans have ESRD, making this expansion one of the broadest to date in terms of the number of beneficiaries potentially affected. Previously, dental coverage for ESRD patients was limited to those who were also preparing for a kidney transplant. The 2025 rule extends coverage to dialysis patients regardless of whether they are on the transplant list.

The second major change in 2025 was the introduction of the KX modifier requirement, effective July 1, 2025. The KX modifier is a billing code that providers must attach to dental claims submitted to Medicare. It serves as an attestation by the provider that the dental services meet the coverage criteria for the specific medical condition being treated. This requirement helps CMS ensure proper billing and prevents routine dental services from being submitted under the expanded coverage categories.

What This Means for Medicare Beneficiaries

For Medicare beneficiaries facing organ transplants, cancer treatment, cardiac valve procedures, or ESRD, these expansions provide meaningful financial relief. Dental work can be expensive, and having Medicare cover the dental care needed before or during treatment for these conditions can reduce out-of-pocket costs significantly.

If you have one of these conditions and your medical team has recommended dental treatment as part of your care plan, ask your provider about submitting the dental services to Medicare under the expanded coverage rules. Your provider will need to include the appropriate documentation and, starting July 2025, the KX modifier on the claim.

It is important to understand the limitations. These expansions cover dental care that is directly linked to the treatment of specific covered medical conditions. They do not cover routine dental care, preventive cleanings, or dental work that is not related to a covered condition. You will still need a separate dental plan or a Medicare Advantage plan with dental benefits for your everyday dental needs.

Medicare Advantage Dental Benefits in Context

While the CMS expansions apply to Original Medicare, most Medicare beneficiaries who want comprehensive dental coverage still rely on Medicare Advantage plans. According to CMS data, approximately 98% of Medicare Advantage plans in 2026 include some form of dental benefit. These benefits range from basic preventive coverage to plans that include major services like crowns, root canals, and dentures.

The CMS expansions and Medicare Advantage dental benefits serve different purposes. The expansions cover dental care tied to specific medical conditions under Original Medicare. Medicare Advantage dental benefits cover routine dental care as an added plan benefit. Beneficiaries enrolled in Medicare Advantage would receive both the expanded medical dental coverage and the plan's supplemental dental benefit.

For beneficiaries who prefer to stay with Original Medicare, the expanded coverage provides a narrow but valuable addition to the dental landscape. Combined with a standalone dental insurance plan, it helps fill some of the dental coverage gaps that have existed in Medicare since the program began.

Looking Ahead: Future Expansions and Advocacy

CMS has added new conditions to the dental coverage framework each year since 2023, and advocacy groups continue to push for further expansion. Organizations representing dentists, patients, and public health have urged CMS to consider additional medical conditions where dental care is clinically important, such as diabetes management, joint replacement, and immunosuppressive therapy for autoimmune conditions.

There are also ongoing legislative efforts to add comprehensive dental, vision, and hearing coverage to Medicare through an act of Congress. These proposals would go far beyond the CMS expansions by adding routine dental care to the Medicare benefit package. However, the cost of such legislation has been a barrier, and no comprehensive dental benefit has been enacted as of early 2026.

In the meantime, CMS has the authority to continue expanding the list of covered conditions through annual rulemaking. Each year's Physician Fee Schedule final rule should be watched for new additions. Beneficiaries with serious medical conditions should stay informed about whether their condition now qualifies for dental coverage under these rules.

The CMS expansions may be incremental, but they represent a real shift in how Medicare treats dental care. For beneficiaries with qualifying conditions, they provide coverage that did not exist just a few years ago. Staying informed about these changes and working with your medical team to access the coverage you are entitled to is an important part of managing your health care costs.

If you are a Medicare beneficiary with a condition that may qualify for dental coverage under these rules, talk to your treating physician about whether dental care should be part of your treatment plan. Your medical team may not be fully aware of the expanded dental benefits, so being informed and asking the right questions can help you access coverage that might otherwise be overlooked.

For dental providers, understanding the billing requirements for these expanded services is essential. The KX modifier, proper documentation of the medical-dental connection, and familiarity with the specific covered conditions are all necessary to submit claims successfully. Providers who treat Medicare patients with qualifying medical conditions should review the annual Physician Fee Schedule final rules for the latest guidance on dental billing.

The link between dental health and overall health is backed by decades of research. CMS has acknowledged this connection through its annual rulemaking, gradually expanding the circumstances under which Medicare will pay for dental services. While comprehensive routine dental coverage remains outside of Medicare's scope, the integral to treatment framework has opened a meaningful pathway for beneficiaries with serious medical conditions to receive the dental care they need.