September 5, 2023
The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1784-P
P.O. Box 8016
Baltimore, MD 21244-8016
Submitted online via www.regulations.gov

Re: File Code CMS-1784-P Medicare and Medicaid Programs; CY 2024 Payment Policies Under the
Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies
Dear Administrator Brooks-LaSure:

The American Association of Oral and Maxillofacial Surgeons (AAOMS) represents more than 9,000
oral and maxillofacial surgeons (OMSs) in the United States. AAOMS commends CMS on efforts toimprove access to high-quality and affordable health care, specifically, the proposals aimed atensuring Medicare beneficiaries have access to medically necessary and essential dental services.
We appreciate the opportunity to comment on the proposed 2024 revisions to the Payment Policies
Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies,
published in the August 7, 2023, Federal Register (Vol. 88, No. 150, pages 52262-53197).

CY 2024 Medicare Physician Fee Schedule rate setting and conversion factor

Medicare providers stand to face another round of significant payment cuts beginning January 1,
2024. In the proposed rule, CMS estimates that the CY 2024 Medicare Physician Fee Schedule(MPFS) conversion factor — the basic starting point for calculating Medicare payments — willbe $32.7476, representing nearly a 3.4 percent decrease from the $33.8872 CF for 2023.

The Medicare payment system has been devalued through recurring and drastic payment cuts year
after year. CMS’s proposal fails to account for the economic factors that have dramatically increased
practice costs in the past year. The CY 2024 MPFS proposed rule jeopardizes the already-strained
financial stability of many physician practices, especially small independent practices. AAOMS
urges CMS and HHS not to finalize the proposed payment cuts and to work with Congress tofundamentally reform the MPFS to ensure reimbursement stability for Medicare providers
moving forward.

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Proposals and request for information on Medicare Parts A and B payment for dental
services
Dental services linked to Medicare-covered cancer treatments
Oral and maxillofacial surgery is the surgical specialty of dentistry and one of the few dental
specialties whose members perform Medicare-covered procedures that range from the removal ofcancerous tumors in the mouth/jaw area and the extraction of infected teeth to preparing apatient’s jaw for radiation cancer treatment to repairing tissue or bones in the facial area following
trauma. As such, our members have extensive experience with the Medicare program.

AAOMS supports efforts to expand Medicare coverage for certain oral and maxillofacial surgery
services1 that the association considers to be “medically necessary” or “essential” because they areintegral in the management of certain acute conditions. We believe such services include theevaluation and definitive treatment of infections of the head and neck prior to, or concurrently withcertain therapies used to treat cancer.

AAOMS appreciates CMS’s consideration of the serious, dental related complications — specifically
medication-related osteonecrosis of the jaw (MRONJ) — that can result from certain
immunosuppressive cancer treatments, such as high-dose antiresorptive and/or antiangiogenic
drug therapy. The data suggest that antiresorptive medications, such as bisphosphonates,
denosumab and certain antiangiogenics are associated with an increased risk for developing
MRONJ2, which can complicate cancer treatment and lead to reduced survival rates post-treatment3.

As CMS has acknowledged, patients with existing dental disease pose the greatest risk fordeveloping MRONJ secondary to bone-modifying therapy3. From a clinical standpoint, prevention of
MRONJ is the gold standard and AAOMS has long emphasized2 the importance of amultidisciplinary, coordinated approach that includes pretreatment dental management inminimizing the risk of MRONJ. As such, AAOMS supports CMS’s proposal to expand Medicare
coverage and payment for dental examinations prior to, as well as diagnostic and treatment
services to eliminate an oral or dental infection prior to or at the same time as, theadministration of high-dose bone modifying agents. AAOMS further supports the expansionof similar coverage of dental diagnostic and therapeutic services, furnished prior to or
concurrently with other Medicare-covered cancer treatments including chemotherapy andchimeric antigen receptor (CAR) T-cell therapy.
Consistent with the policy changes finalized in the CY 2023 Medicare Physician Fee Schedule final
rule4, AAOMS supports CMS’s proposal to allow Medicare payment for services that are
ancillary to, or provided in conjunction with, covered dental services such as X-rays,
administration of anesthesia, use of the operating room and other facility services for theabove listed clinical scenarios. AAOMS continues to believe such services represent necessary
diagnostic, clinical and procedural considerations that must be determined by the surgeon on acase-by-case basis.

Proposal to clarify coverage and payment for dental services linked to covered treatment of head andneck cancer
AAOMS wishes to commend CMS on its proposal to clarify coverage and payment for medicallynecessary dental services linked to Medicare-covered treatments for head and neck cancer (HNC).
As noted, the term “head and neck cancer” refers to a group of cancers that originate in various

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areas of the head and neck, with the mucosal surfaces of the oral cavity, pharynx and larynx being
most common5. These cancers are often grouped together because they share common risk factors,
symptoms and treatment approaches.
Clinical evidence supports that HNC may be locally advanced or metastatic5,6. Although, asacknowledged by CMS diagnostic and therapeutic treatment approaches to HNC remain
fundamentally similar whether primary, metastatic or metachronous6.

As such, AAOMS supports CMS’s proposal to clarify that Medicare payment may be made fordental or oral examination performed as part of a comprehensive workup in either the
inpatient or outpatient setting, as well as for the medically necessary diagnostic andtreatment services to eliminate an oral or dental infection prior to the initiation of, or
during, treatments for head and neck cancer, whether primary or metastatic, regardless ofsite of origin, and regardless of initial modality of treatment.
Request to consider Medicare payment for post-radiation dental services

AAOMS reiterates its request for CMS to consider coverage for certain post-radiation dental
services linked to HNC. As noted in previous comments, radiotherapy plays a significant role in thetreatment of HNC with approximately 80 percent of all HNC patients receiving radiotherapy at least
once during the course of their disease7.

Oral toxicities related to HNC treatment, whether radiotherapy, chemotherapy or combination
treatment with concurrent systemic agents are well documented and include, but are not limited to,mucositis, hyposalivation, dysphagia, osteoradionecrosis and radiation-related caries7,8,9,10,11. These
oral toxicities may be acute (developing during active treatment) or late onset (manifesting several
months after treatment is complete) with some latent complications of radiotherapy linked topermanent tissue damage5,7 as well as damage to bony structures, tissues and salivary glands. In
addition, current data show approximately 30 percent of HNC patients develop radiation caries
within 12 months following completion of radiotherapy12.

Outside of the deterioration of dental and periodontal health, the management of long-term chronic
effects of radiotherapy, such as mucosal pain and recurrent infection, salivary gland dysfunction
and osteoradionecrosis contribute significantly to disease burden and national health care costs as
the economic consequences of preventing and managing oral complications of cancer therapy canbe substantial13,14. For example, incremental costs for the conservative management of
osteoradionecrosis ranges between approximately $4,000-$35,000 and between $5,000-$30,000
for management of oral mucositis in cancer patients undergoing radiotherapy14. Elting & Chang
attribute this high cost both to the resource-intensive settings in which management of oral
complications typically takes place and the complex needs of cancer patients including enteral andparenteral feedings, febrile neutropenia and frequency hospitalizations14.

In general, medical standards of cancer care include routine follow-up, supplemental or secondary
treatments for symptom management and long-term management of overall health. It stands toreason that oral and dental care should be incorporated into clinical cancer care protocols for pre-,intra- and post-treatment, especially for diagnoses or therapies known to cause oral complications.
Access to medically necessary dental services post-radiation may positively impact patient qualityof life and mitigate some of the resource-intensive treatment of advanced oral sequalae of HNC. As
such, AAOMS encourages CMS to consider the expansion of Medicare coverage to include
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medically necessary dental services occurring postradiotherapy for beneficiaries with adiagnosis of head and neck cancer.
Consideration of dental services prior to radiation therapy in the treatment of head and neck cancer
as inextricably linked
As noted above, radiation therapy or radiotherapy remains a standard form of treatment for manytumors of the head and neck region7,15. Oral complications, as well as potential damage to the hardand soft tissues of the head and neck resulting from cancer treatment — including radiotherapy —are well documented.

Radiotherapy can lead to a decrease in cellular proliferation rate, apoptosis15 and neutropenia16, allof which may significantly increase the patient’s susceptibility to illness and infection16 during
treatment and in the post-radiation period. Although, exactly how radiotherapy affects the immune
system may be dependent on several factors, including total radiation dose, the part of the bodybeing irradiated, how much of the body is being treated and whether radiation is administered inconjunction with chemotherapy16. Clinical evidence indicates the cell-damaging properties ofradiation therapy are nonspecific15, meaning cells and tissues in and around the treatment area canbe affected. For HNC, this may include the oral mucosa, salivary glands, maxillary and mandibularbone, teeth and/or masticatory muscles15.

In general, pre-radiation dental treatment aims to eliminate or prevent infection and to minimize
the risk and/or severity of radiation-related oral toxicities including oral mucositis, oropharyngeal
candidiasis, xerostomia and radiation-related caries17. In addition, this dental treatment may also
include necessary oral surgery (extraction(s) and/or preprosthetic surgery) done prior to the
exposure to high dose radiotherapy. This would help avoid the potential healing difficulties thathave been well documented related to the reduced blood supply that results in the irradiated areas.
While some of the side effects of radiotherapy cannot be avoided, there is some research to suggest
pre-radiation dental management may be a factor in mitigating the risk of developing serious
complications, such as osteoradionecrosis15,18,19.

We note it has been a longstanding CMS policy20 to permit Medicare payment for extractions done
to prepare the jaw for radiation treatment of neoplastic disease. However, pre-radiation dental
treatment protocols vary17 and invasive procedures such as tooth extraction may not be indicated21
for certain patients, depending on several factors including, but not limited to, planned radiation
schedule, dosage and the type of radiotherapy to be administered. It stands to reason that, in suchcases there may be other diagnostic and therapeutic dental services necessary to identify, diagnose
and treatment an oral or dental infection that may be more appropriate. A 2022 systematic review
and meta-analysis22 found only weak correlation between pre-radiation tooth extractions andincreased risk for osteoradionecrosis development however, it is still the case that invasive surgicalprocedures to eliminate or prevent dental/oral infections prior to initiating radiotherapy may not
be clinically indicated in certain circumstances.
As such, AAOMS encourages CMS to extend coverage to examinations, as well as otherdiagnostic and therapeutic dental services furnished to identify, diagnose and treat oral ordental infections prior to the initiation of Medicare-covered radiation treatments for headand neck cancer.

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Request to align coverage and payment policies to include ASCsAAOMS continues to believe that access to procedures described above, as well as those finalized
under the Medicare Physician Fee Schedule CY 2023 final rule is often critical to successful
outcomes for patients with certain acute conditions. As OMSs routinely evaluate and safely treat
patients ranging in complexity across a variety of care settings, AAOMS supports Medicare coverageof these services in either the inpatient or outpatient hospital setting.

Under the CY 2024 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory
Surgical Center (ASC) Payment System proposed rule23, CMS has proposed to assign 229 dental
procedure codes to clinical Ambulatory Payment Classifications (APCs). This would allow hospital
outpatient departments to receive facility payment for dental services that meet Medicare coverageand payment criteria, if finalized. We believe this proposal supports CMS’s dental coveragepolicies finalized in the CY 2023 MPFS final rule, as well as those outlined in the CY 2024
MPFS proposed rule.
In the CY 2024 OPPS/ASC CMS proposed rule, CMS further proposes to add 26 dental surgicalservices to the ASC Covered Procedures List, identifying them as safe to perform and payable byMedicare in the ASC setting. AAOMS encourages CMS to align the coverage and payment
policies under the MPFS with these proposals.

As it stands, dental services performed to identify, diagnose and treat oral or dental infections prior
to or contemporaneously with Medicare covered organ transplant surgery, cardiac valve
replacement and valvuloplasty procedures, as well as covered treatments for head and neck cancer
beginning in 2024 and the proposals outlined in the 2024 MPFS proposed rule, Medicare coverage
is limited to hospital inpatient and outpatient settings. Services to eliminate an oral or dental
infection may include, but are not limited to, the extraction of teeth, intraoral and extraoral incisionand drainage procedures and partial ostectomy/sequestrectomy for removal of non-vital bone, allof which are surgical procedures CMS proposes to allow payment when furnished in the ASC,
providing all Medicare coverage and payment criteria are met. Permitting Medicare payment in the
ASC for inextricably linked and medically necessary dental surgical services furnished to identify,
diagnose and treatment oral or dental infections prior to, or at the same time as, select covered
medical procedures would help to ensure the consistent application of Medicare dental coverageand payment policies across care settings.
Further, we believe that ASCs have the potential to mitigate many of the external pressures thatcurrently act as barriers in access to care. The lack of and/or limited hospital-based OR access is
exacerbated by ongoing medical staffing shortages and industry-wide inflation. Other challenges
exist for patients unable to access hospital facilities because of geographic or transportation
limitations. Indeed, industry research indicates the health care system as a whole benefits whenprocedures migrate to less costly care settings. As such, AAOMS encourages CMS to align coveragepolicies under the MPFS and the ASC payment system to allow Medicare coverage andpayment for dental surgical services to identify, diagnose and treat oral or dental infections,when inextricably linked to the clinical scenarios finalized in the 2023 MPFS final rule andthose proposed in the 2024 MPFS proposed rule.

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Additional clinical scenarios for dental services integral to other covered medical services
AAOMS appreciates CMS’s acknowledgement of our Association’s recommendations related to
Medicare coverage and payment for select dental services linked to other covered cardiovascular
procedures and total joint arthroplasties. We recognize that CMS holds the view that the existing
clinical evidence and scientific literature do not substantiate the inherent connection between theseprimary surgical procedures and dental services aimed at eradicating an oral/dental infection.
AAOMS will continue to explore whether there is new or alternative evidence related to theseclinical scenarios to support the inextricable linkage with select dental services.
Request for information on the implementation of payment policies for dental services
Medicare denial to support third-party primary payment
In the proposed rule, CMS seeks comment on the “informal practice” of dental professionals
submitting a dental claim to Medicare for the purpose of obtaining a denial so that another carrieror third-party payer may issue primary payment. Given the dental surgical nature of many oral andmaxillofacial procedures, OMSs routinely submit claims to both dental and medical carriers, as
appropriate. The need to produce a denial for non-covered services is particularly impactful forcases that involve both types of plans.

According to Section 950 of the Medicare Prescription Drug, Improvement, and Modernization Act
of 2003 (MMA) 24, prohibits secondary or supplemental group plans from requiring dental
providers to file claims for services excluded from coverage under §1862(a)(12) of the Social
Security Act. We note that MMA does not preclude a group plan from requiring such a
determination in cases involving, or appearing to involve inpatient dental services, or other dental
services that may be covered by Medicare. However, there are many dental services and clinicalscenarios for which Medicare payment is not permitted and therefore MMA may apply.

AAOMS is aware that some dental insurance carriers routinely require a denial or adverse
determination from a medical carrier — which may include Medicare — for certain dental
services or codes. AAOMS opposes this practice. This process can be administratively
burdensome to dental providers, create significant delays in claims reimbursement and may be
confusing or frustrating to patients. Therefore, it may not be so much as an informal practice but
rather a requirement for dental claims adjudication, under certain circumstances.

When submitting dental services to Medicare for purposes of a denial, CMS notes the appropriate
HCPCS modifier(s) must be included on the dental claim form to indicate the billing practitioner
does not believe Medicare payment is warranted. We wish to clarify that neither the 2019 (current)
version of the ADA Dental Claim form, nor the version slated to take effect Jan. 1, 2024, include abox or field for HCPCS modifier use. AAOMS in not aware of any medical carriers that currently
accept the dental claim form, therefore when a medical denial must be obtained for a dental service,
the CMS-1500 form (or ANSI ASC X12N 837P electronic transaction) is typically used.

Contractor pricing and data to inform appropriate payment for dental services

AAOMS continues to support CMS’s proposal to retain carrier pricing methodology for thedental services for which payment is currently made under the MPFS, as well as for thosedental services that may be paid under the CMS proposals beginning in CY 2024.
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Additionally, we support suggestions that certain publicly available data sources, such as
FAIR Health may provide meaningful cost and utilization data to inform appropriate
payment for dental services. Specifically, the FAIR Health database includes25 claims data forservices rendered in all areas of the U.S., which could aid Medical Administrative Contractors indetermining dental payment rates that appropriately account for geographic variation.
MPFS payment indicators for CDT©1 codes

AAOMS commends CMS for the guidance issued to local Medicare contractors in June to revise the
RVU file that applied MPFS payment indicators to CDT© codes. We reiterate comments submitted
by the ADA on behalf of all dental specialties that multiple procedure reductions and other payment
reductions applicable to covered CPT©2 codes should not apply to CDT© codes or dental services.
Primarily, this is because the global surgery concept does not apply to CDT©.
According to Chapter 1 of the National Correct Coding Initiative Policy Manual26, the rationale forthe multiple surgery payment reduction stems, in part from code valuation in relation to the global
period:“Most medical and surgical procedures include pre-procedure, intra-procedure, and postprocedure work. When multiple procedures are performed at the same patient encounter,
there is often overlap of the pre-procedure and post-procedure work. Payment methodologies
for surgical procedures account for the overlap of the pre-procedure and post-procedure
work.”

Unlike CPT codes, where surveys are used to establish RVU’s as well as parameters to refine global
periods, there is no survey data that establishes what comprises pre-service and post-operative
services that may arise as a consequence of a primary dental procedure, or the duration (e.g.,number of postoperative visits) of a reasonable period that could be designated as a global period.

AAOMS continues to believe that, lacking structured survey data to inform the existence ofoverlap in pre- and post-procedure physician work, it is inappropriate to apply payment
reductions based on such parameters to CDT© codes.
AMA RUC as the entity best positioned to provide resource inputs for physician work andpractice expense

Lastly, AAOMS offers support for the current AMA/Specialty Society RVS Update Committee (RUC)
process and mirrors the sentiment of many in the healthcare industry that AMA RUC is the entity
best positioned to provide accurate, relevant resource data to support physician work and practice
expense valuations.

The RUC process is robust and transparent. AAOMS believes it plays a significant role indetermining the relative value of medical procedures and services. We support the RUC process andacknowledge the physicians and healthcare practitioners representing over 100 specialty societiesand disciplines who continue to dedicate their time and clinical expertise to the RUC process.
1 CDT© is a registered trademark of the American Dental Association.

2 CPT© is a registered trademark of the American Medical Association.

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Thank you for your consideration of these comments. Please contact Patricia Serpico, AAOMS
Director of Health Policy, Quality and Reimbursement, with any questions at 800-822-6637, ext.
4394 or pserpico@aaoms.org.
Sincerely,

Paul J. Schwartz, DMD
AAOMS President

Joshua E. Everts, DDS, MD, FACS
Chair, AAOMS Committee on Healthcare Policy, Coding & Reimbursement

Page 8References
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