01 Sep Adding Dental Coverage to Medicare Could Be Crucial For Oral, Head and Neck Cancer Patients and Survivors
Written by Wey-Wey Kwok, JD
The Center for Medicare Advocacy (CMA) is a non-profit, public interest law organization headquartered in Connecticut and Washington, D.C., that works to advance access to comprehensive Medicare coverage, health equity, and quality health care for older people and disabled adults. Founded in 1986, CMA focuses on the medical care needs of people with long-term and chronic conditions. Our work includes legal assistance, advocacy, education, analysis, policy initiatives, and litigation of importance to Medicare beneficiaries nationwide. Our systemic advocacy efforts are based on the experiences of those who contact the Center each day with their concerns.
Dental Needs of Medicare Beneficiaries with Oral, Head, and Neck Cancer
CMA regularly hears from Medicare beneficiaries who are facing dental and oral complications as a result of oral, and head and neck cancer (OHNC) treatment. Some people, particularly those who have undergone primary radiation therapy, or in association with surgical treatment, face complications that often prove very challenging. These complications or side effects include oral pain, dysfunction and infections, and significant related damage to the teeth, mucous membranes and soft tissues, bone, salivary glands and oral blood supply. These changes can deeply affect the individual’s comfort, ability to chew and swallow, which in turn affect overall level of nutrition, and consequently general health and quality of life.
Prevention and management of dental and oral complications are crucial for oral, head, and neck cancer patients and survivors. There are many, though, who have difficulty affording and accessing the medically essential oral and dental care. CMA often gets calls from people seeking clarity on what dental services Medicare will and will not pay for in their situation, whether dental professionals (e.g., oral-maxillofacial surgeons, prosthodontists, general dentists) requiring up front payment for the services they need, and whether their claims are worth appealing to Medicare.
Medicare’s Dental Coverage Gap
Dental/oral health benefits are not a part of the Traditional Medicare program. A provision in the Medicare statute prohibits payment for “services in connection with the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth.” The federal agency has long interpreted this language to bar coverage for nearly all dental work, including preventive and diagnostic services such as exams, x-rays, and cleanings, as well as restorative procedures like fillings, extractions, periodontal care, root canals, crowns, bridges, dentures, and implants.
While many private Medicare Advantage (MA) plans offer dental benefits, those benefits may be limited in scope of services, coverage amount, and provider network. Persons who are considering enrolling in an MA plan should seek out and evaluate the details of the plan’s dental benefits.
Extremely Limited Coverage for “Medically Necessary” Dental Procedures
Medicare beneficiaries are often shocked to learn that Medicare typically will not even cover care to address dental problems that are caused by a medical condition or treatment, or that could well jeopardize their medical condition or treatment. For example, it will not cover care for rampant tooth decay and gum disease resulting from radiation, chemotherapy, or prescribed medications or diseases that affect the functioning of the salivary glands. Nor will Medicare pay for dental care that someone must have to obtain clearance for a critical medical procedure, such as heart surgery, organ transplant, or treatment for leukemia.
What Medicare Will Cover
Medicare’s current dental policy generally limits coverage to the following procedures:
- Surgery related to the jaw and orofacial structures (e.g., skull, palate, tongue, salivary glands, sinuses, etc.), such as to repair a fracture or remove a tumor
- Extractions needed to prepare the jaw for radiation treatment of cancer
- Inpatient oral examination prior to kidney transplant
- Dental items and services provided in connection with a primary covered service that the dentist is performing. For example, if the dentist must extract a tooth as a part of repairing a fracture or removing a tumor, then the entire procedure will be covered, including the extraction which normally would not be covered.
Tips for Beneficiaries
Beneficiaries who need the above-mentioned covered services should make sure to seek care from a provider who is enrolled in Medicare. Beneficiaries have a right to appeal denials of coverage. They can initiate an appeal by following the directions on the Medicare Summary Notice that reflects the coverage denial. The first two levels of appeal are paper reviews performed by contractors. At the third stage, conducted by an administrative law judge (ALJ), the beneficiary can choose to present supporting arguments and testimony at a telephonic hearing. At each of these stages, the beneficiary can submit additional evidence, such as supporting letters from their physicians. Two additional levels of appeal are available, assuming that the amount in controversy requirements are met.
MA plans are also required by law to cover these services, and a plan enrollee can appeal if the plan denies prior authorization. The enrollee should make sure to seek care from a provider who can be paid by the plan. If a dentist or dental specialist has opted out of Medicare enrollment, neither they nor their patients can be reimbursed by a MA plan or traditional Medicare.
Efforts to Expand Medicare Dental Coverage
CMA has long felt that Medicare’s dental policy is unduly restrictive. The policy essentially disallows payment for any work performed on the teeth and supporting structures, regardless of the medical reasons why the individual may need the procedures. Only in extremely limited circumstances will Medicare make an exception to allow payment for normally non-covered dental services. The following is a link to the text of the dental policy (See Section 150, which is on page 137): https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf.
Over a decade ago, beneficiaries were sometimes able to win coverage for their dental claims at the ALJ (administrative law judge) appeal stage. Since then, however, such victories are highly rare, and the agency has successfully sought to overturn any favorable ALJ decisions granting coverage of dental treatments. This has proven very frustrating for beneficiaries. CMA’s attempts to appeal these denials to the federal courts were ultimately unfruitful, as the courts have upheld the agency’s restrictive dental policy.
For the past several years, CMA has been working to seek policy and/or statutory change to establish better dental coverage in Medicare. The organization has been working in broad coalition to try to get the agency to expand its definition of what is coverable “medically necessary” dental care. It has also been working to get Congress to pass legislation that would add a comprehensive dental benefit to Medicare Part B.
What You Can Do to Support Adding a Dental Benefit to Medicare
At the present time, there is real interest and activity in Congress around addressing the vital need for dental coverage in Medicare. The proposal to add a dental benefit to the program is being considered as part of the infrastructure and budget reconciliation package that Congress is negotiating this summer.
Legislators are finally starting to understand what the public has known all along – that oral health is a key part of overall health. Recent Morning Consult and YouGov polling shows that 8 out of 10 adults support including dental coverage in Medicare, and that the proposal is highly popular among U.S. voters across the political spectrum.
Because the current moment presents a truly rare opportunity to legislate a meaningful dental benefit in Medicare, it is a crucial time for people to contact and urge their federal lawmakers to make this important improvement to the program for current and future generations of Medicare beneficiaries. If Congress misses this chance, it could be a very long time before we will see another opportunity.
The following link allows you to send an automatic email to your members of Congress asking them to support adding a comprehensive dental benefit to Medicare: https://secure.everyaction.com/pa3W02ObtUqwRFH6-stqoQ2.
If you prefer to call or write a letter to your elected representatives, you can obtain the contact information for your U.S. Senators on the “Find Your Senators” pull-down menu on the following site: https://www.senate.gov/. You can obtain the contact information for your U.S. Representative by typing in your zip code at the following webpage: https://www.house.gov/representatives/find-your-representative.
How to Share Your Story
CMA encourages Medicare beneficiaries to share their oral health stories with us at OralHealth@MedicareAdvocacy.org. They should also indicate if they would be willing to speak to the press or to policy makers. Sometimes reporters ask CMA for beneficiary stories when they are writing an article that highlights how Medicare’s restrictive dental policy harms beneficiaries. These articles can really help the public and policy makers understand the human impact of not having dental coverage in Medicare.
People can also share their oral health experience at the Families USA story bank through this link: https://familiesusa.org/share-your-story/. The story bank is used in ongoing advocacy efforts to expand dental coverage as well.
Contacting the Center
Anyone can contact CMA to obtain information and assistance with our many factsheets and self-help packets, available for free on our extensive website. Please note that CMA is only funded to provide direct legal assistance for people from Connecticut. We do have certain substantive priorities and can sometimes provide limited assistance to people outside of Connecticut with those concerns – including, for example, advancing Medicare coverage for oral health care. Our phone number is (860) 456-7790 and our website is: www.medicareadvocacy.org.
1 42 U.S.C. § 1395y(a)(12).
2 Note: Pursuant to a local coverage determination (LCD) issued by the Medicare regional contractor Palmetto GBA, that processes claims submitted by providers in Alabama, Georgia, Tennessee, North Carolina, South Carolina, Virginia and West Virginia, coverage is available in those states for the insertion of metallic implants when “used to assist in or enhance the retention of a dental prosthetic as a result of a covered service.” [L34574]. https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34574
3 For more detailed information on Medicare’s dental coverage policy, refer to the Medicare Benefits Policy Manual Chapter 15, §§ 150 [Dental Services], 150.1 [Treatment of Temporomandibular Joint (TMJ) Syndrome], and 120-C [Prosthetic Devices – Dentures].
4 Currently, oral appliances for treating obstructive sleep apnea are covered by Medicare as durable medical equipment pursuant to local coverage determinations.
Editors Note: Wey-Wey Kwok has been an attorney with the Center for Medicare Advocacy since 2002. In addition to her litigation and policy work, she also specializes in hospice coverage, and represents Medicare beneficiaries in appealing coverage denials of home health and skilled nursing facility care. She is an active member of the New York Bar.