The Evolution of Medical Necessity for Dental Services in the Proposed 2023 Medicare Fee Schedule Rule | donelson baker

Historically, Medicare has only paid for dental services in certain limited circumstances where a service is an integral part of a specific treatment of a beneficiary’s primary medical condition. Legislative efforts to expand Medicare coverage of dental services have fallen short once again, leaving lawmakers and CMS grappling with how seniors can receive broader access to dental care. On a June 29, 2022, letter to CMS Administrator Chiquita Brooks-LaSure, more than 100 members of the US House of Representatives indicated that CMS could increase Medicare coverage of some dental services by broadening its definition of “medically necessary” dental care. In the letter, lawmakers highlighted the serious problems stemming from seniors’ lack of access to affordable dental care, which is a point dental advocates have been advocating for years.

Nearly half of Medicare beneficiaries have not seen a dentist in the past year, nearly 20 percent of seniors have lost all of their teeth, and 68 percent have periodontal disease, a condition that causes tooth loss. the soft and hard tissues that support the teeth in the mouth. .1 The lawmakers made an important point in their letter by explaining that the definition of medical necessity for dental services does not reflect current research-based understandings. Research over the past 10 years has shown that oral health is essential to overall health.two It has been proven that more than 90 percent of all systemic conditions have oral manifestations.3 Additionally, poor oral health can exacerbate chronic diseases such as diabetes, dementia, respiratory and heart disease that are prevalent in the aging population.4

In the FY 2023 Medicare Medical Fee Schedule Proposed Rule (proposed rule), CMS proposes to codify a broader interpretation of Medicare coverage for dental services in an effort to provide seniors with better access to vital dental care that can improve medical outcomes.

Proposed coverage for dental services inextricably linked, substantially related, and integral to the clinical success of other covered medical services

In the Proposed Rule, CMS seeks to clarify Section 1862(a)(12) of the Social Security Act, which allows Medicare Part A payment for inpatient hospital services in connection with the provision of dental services if the individual, due to his or her underlying medical condition and clinical status or the severity of the dental procedure, requires hospitalization in connection with the provision of such services.

CMS expresses its belief that there are instances in which a Medicare beneficiary may require dental services that are directly related to the care, treatment, filling, removal, or replacement of teeth or structures that directly support teeth (generally excluded from coverage). ) and the Medicare app. The Part A payment would apply when hospitalization of the patient is required due to (1) the patient’s underlying medical condition and clinical status, or (2) the severity of the dental procedure.

CMS differentiates services that are covered because they are “substantially related to and integral to the success of other covered medical services” from services that are “related to dental services” within the meaning of Section 1862(a)(12). Based on this distinction, CMS interprets Section 1862(a)(12) to allow Medicare payment under Parts A and B for these dental and related services that are “inextricably linked and substantially related to and integral to the success clinician Of, certain other covered medical services,” regardless of whether the services are provided in an inpatient or outpatient setting. In summary, CMS proposes to clarify that the Section 1862(a)(12) exclusion would not apply because these services are not related to the care, treatment, filling, removal or replacement of teeth or structures supporting teeth Rather, in these circumstances, dental services would be covered as they are inextricably linked to and substantially related to and integral to the success of certain other covered services medical services.

Based on this interpretation, CMS proposes to amend its regulation at § 411.15(i) to clarify that the Section 1862(a)(12) exclusion does not apply to dental services provided in conjunction with medical services that are inextricably linked and substantially related to and integral to the clinical success of covered medical services.

In the proposed rule, CMS also expressed its belief that dental services provided to identify, diagnose, and treat oral or dental infections prior to organ transplantation, heart valve replacement, or valvuloplasty are included in the exception for services that are inextricably linked and substantially related to and integral to the clinical success of these other covered medical services. CMS specifically notes that in these circumstances, the treatment necessary to eradicate an infection may not be the full range of dental services recommended for a given patient. To the extent such services are deemed immediately necessary to eliminate or eradicate the infection or its source prior to surgery, they shall be deemed inextricably linked and substantially related to and integral to the clinical success of the organ transplant, heart valve replacement, or related services. of valvuloplasty.

To codify this, CMS proposes to amend § 411.15 to include examples of such services that would be payable under Medicare Parts A and B as dental services that are inextricably linked to, and substantially related to, and integral to the clinical success of other covered medical services, including but not limited to:

  1. Dental or oral examination as part of a comprehensive workup prior to an organ transplant, heart valve replacement, or valvuloplasty procedure;
  2. Dental diagnostics and treatments necessary to eliminate oral or dental infections found during a dental or oral examination as part of a comprehensive work-up prior to an organ transplant, heart valve replacement, or valvuloplasty procedure;
  3. Reconstruction of a dental ridge when performed as a result of and at the same time as surgical removal of a tumor;
  4. Wiring or immobilization of the teeth when performed in connection with the reduction of a jaw fracture;
  5. The removal of teeth to prepare the jaw for radiation treatment of neoplastic diseases; Y
  6. A dental splint, but only when used in conjunction with covered treatment of a medical condition.

CMS also proposes that Medicare Parts A and B payment be made for these dental services, as applicable, regardless of whether they are provided in an inpatient or outpatient setting. In addition, payment under the applicable payment system may be made for ancillary services and supplies provided in connection with these covered dental services, such as x-rays, administration of anesthesia, and use of an operating room, whether or not the services are provided. in the hospital or outpatient setting.

MACs may continue to make coverage decisions on a claim-by-claim basis

Under current policy, CMS has delegated the authority to MACs to decide, on a claim-by-claim basis, whether a patient’s circumstances fit the coverage exclusion or exception set forth in Section 1862(a)(12) and § 411.15 ( i) of the act. Similarly, the proposed rule would not prevent a MAC from determining that dental services may be covered in other circumstances not specifically addressed in the proposed rule and the proposed amendments to § 411.15(i).

Call for Comments

Finally, the proposed rule requests comments on a number of issues, including but not limited to:

  • Other types of clinical situations in which dental services may be inextricably linked and substantially related to and integral to the clinical success of other covered medical services;
  • The possible establishment of a process to identify and review submissions for CMS consideration of additional dental services that are inextricably linked and substantially related to and integral to the clinical success of other covered medical services;
  • Whether there are other clinical scenarios involving acute or chronic conditions that would have a better patient outcome if dental services were provided, and if so, whether these services should be considered inextricably linked to, and substantially related to, and integral to the clinical success of, certain covered medical services;
  • If current policies for care management services make it clear that the time physicians or non-physician practitioners spend coordinating care with dentists related to service performance and outcomes can be counted toward effects of applicable care management codes;
  • Whether the proposed rule policies will address any inequitable distribution of dental services for Medicare beneficiaries; Y
  • Ways to integrate payment for oral health and dental services into existing and future payment models using the Innovation Center’s waiver authority into existing or future service delivery models, including those focused on equity, coordination of care, total cost of care, and specific diseases.

The proposed rule is a ray of hope that seniors may eventually have broader access to affordable dental services. It also acknowledges a better understanding that the oral cavity, the mouth, is, as most dental professionals would say, the window to overall health.

1 US Congress June 29, 2022 Letter to Chiquita Brooks-LaSure.

two University of Illinois at Chicago School of Dentistry, The Surprising Connections Between Oral Health and Wellness (January 14, 2019), https://dentistry.uic.edu/news-stories/the-surprising-connections-between-oral-health-and-well-being/ (last visit on July 31, 2022).

3 US Congress June 29, 2022 Letter to Chiquita Brooks-LaSure.

4 health matters, Medicare dental benefit will improve health and lower health care costs (February 28, 2019) https://www.healthaffairs.org/do/10.1377/forefront.20190227.354079/full/ (last visit on July 31, 2022).

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