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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process.  
 
You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, 
Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
following services when provided by a contracted dental provider: 
Diagnostic: 
- Comprehensive oral exam - once every three calendar years 
- Periodic oral evaluations - two every calendar year 
- Limited oral evaluations - three every calendar year 
- Intra-oral x-ray image of the entire mouth (full mouth series or panoramic image) - once every three calendar 
years 
- Horizontal bitewing x-ray images- once every calendar year 
Preventive: 
- Routine cleaning - two every calendar year 
- Periodontal maintenance (following active therapy) - four every calendar year 
- Fluoride treatments - two every calendar year 
- Minor treatment for pain relief (emergency) 
Basic Restorative: 
- Amalgam or resin fillings - once per tooth every two calendar years 
- Inlays/onlays - once per tooth every five calendar years 
- Protective restorations - once per tooth per lifetime 
Oral Surgery: 
- Simple and surgical extractions - once per tooth per lifetime 
- Other surgical procedures, including alveoloplasty and vestibuloplasty - once per quadrant or arch per lifetime 
Periodontics: 
- Periodontal surgery or scaling and root planing - once per quadrant every three calendar years 
- Full mouth debridement - once every three calendar years 
Endodontics: 
- Root canal treatment, re-treatment root canal therapy, apicoectomy, and pulpotomy - once per tooth per 
lifetime 
Prosthetic Maintenance: 
- Bridge or denture repair - once per arch every calendar year 
- Adjustment to dentures - two adjustments per arch every calendar year 
- Tissue conditioning - allowed in conjunction with fabrication of new denture 
- Repair, replace, or add teeth to existing partial or full dentures - once per tooth per calendar year 
- Re-base and reline dentures - once per denture every three calendar years 
- Re-cement bridges, crowns, onlays and inlays crowns - once per tooth every two calendar years 
Adjunct General Services: 
- General anesthesia - when clinically necessary 
Prosthodontics and Crowns: 
- Dentures (complete, partial, or immediate) - once per tooth every five calendar years 
-  Fixed bridges, crowns, post and core or crown buildup - once per tooth every five calendar years 
 
You can find this information on pages 61-63 of the Plan's 2020 Evidence of Coverage (EOC).