January 30, 2023
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: Dental Recommendations for CY 2024 Review
Submitted via MedicarePhysicianFeeSchedule@cms.hhs.gov

Re: Dental Recommendations for CY 2024 Review
Dear Sir/Madam:
The American Association of Oral and Maxillofacial Surgeons (AAOMS) appreciates the opportunity torecommend additional clinical scenarios for CMS’ consideration of medically necessary dental services inadvance of the CY 2024 Medicare Physician Fee Schedule Proposed Rule.
AAOMS represents more than 9,000 oral and maxillofacial surgeons (OMSs) in the United States. OMSs
specialize in the diagnosis and treatment of disease, injury and defects of both hard and soft tissues ofthe mouth, face and jaws. Oral and maxillofacial surgery is a surgical specialty of dentistry and one of
the few dental specialties whose members routinely perform Medicare-covered procedures. As such,our members have extensive experience with the Medicare program.
AAOMS supports CMS’ efforts to ensure access to medically necessary dental services for scenarios inwhich such services are both clinically advisable to eliminate a dental/oral infection and integral tooverall clinical success. The AAOMS Committee on Healthcare Policy, Coding and Reimbursement hasdeveloped the following recommendations based on current standards of care for patients presenting
with diagnoses related to head and neck cancer or medication-related osteonecrosis of the jaw as wellas those requiring total joint replacements and cardiovascular surgery. We hope to work with CMS on
the recommendation of medically necessary dental services.

Recommendations for additional clinical scenarios for CY 2024
Head and neck cancer: Consideration of Medicare payment for post-radiation dental services
Head and neck cancer (HNC) represents approximately 6 percent of all malignancies, with over 500,000
new cases diagnosed worldwide each year1. Radiotherapy continues to play 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 disease2. Oral complications related to HNC treatment, whether
chemotherapy, radiotherapy or combination treatment with concurrent systemic agents are well
documented2,3. Oral toxicities resulting from HNC treatment include, but are not limited to oral

mucositis, hyposalivation, dysphagia, osteoradionecrosis and radiation-related caries 2,3,4,5,6. 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 to permanent tissue
damage2,7. In addition, current data show approximately 30 percent of HNC patients develop radiation
caries within 12 months following completion of radiotherapy1.
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 andosteoradionecrosis contribute significantly to disease burden and national health care costs as the
economic consequences of preventing and managing oral complications of cancer therapy can besubstantial8,9.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 radiotherapy9. Elting & Chang attribute this high cost both to
the resource-intensive settings in which management of oral complications typically takes place and thecomplex needs of cancer patients including enteral and parenteral feedings, febrile neutropenia andfrequency hospitalizations8.
The National Cancer Institute recommends that dental and oral health professionals be considered partof the cancer care team10. This recommendation is supported by contemporary scientific literature
which indicates that effective management of the complex oral health needs of HNC patients requires amultidisciplinary approach that includes dental specialists and other oral health professionals10,11,12. 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 to reason
that oral and dental care should be incorporated into clinical cancer care protocols for pre-, intra- andpost-treatment, especially for diagnoses or therapies known to cause oral complications, whether acuteor chronic. Access to medically necessary dental services post radiation may positively impact patient
quality of life and mitigate some of the resource-intensive treatment of advanced oral sequalae of HNC.
AAOMS supports CMS’ decision to allow Medicare Parts A and B payment for a dental or oral
examination performed as part of a comprehensive workup, as well as the medically necessary
diagnostic and treatment services to eliminate an existing or potential oral or dental infection, prior to
or contemporaneously with Medicare-covered treatments for head and neck cancer (HNC) beginning in
CY 2024. However, we encourage CMS to consider the expansion of Medicare coverage to include
medically necessary dental services occurring postradiotherapy for beneficiaries with a diagnosis ofhead and neck cancer.
Head and neck cancer: AAOMS comments on definition and policy scope
In the CY 2023 Medicare Physician Fee Schedule Final Rule, CMS indicated a possible need to further
refine and/or clarify certain aspects of CY 2024 policy changes regarding HNC, including the term “headand neck cancer” itself. AAOMS agrees with CMS that this term encompasses several conditions that
often require multimodal therapies, and we do not believe this is inappropriate or unclear.
HNC statistics indicate the majority of cancers of the head and neck region are squamous cell
carcinomas originating in the mucosal surfaces of the oral cavity, pharynx and larynx7. HNC may also
arise in the salivary glands or paranasal sinuses and nasal cavity, although these manifestations are lesscommon7. HNC typically originates within one of these primary sites although occasionally, it issecondary in nature7,13. There is clinical evidence that HNC can be locally advanced or metastatic7,13.

Broadly speaking however, whether primary squamous cell carcinoma, metastatic or metachronous,
clinical diagnostic and therapeutic approaches for HNC remain fundamentally similar13. As outlined
above, treatment modalities for HNC have been historically linked to both acute and chronic oral
toxicities which may cause damage to bony structures, tissues and salivary glands, both directly andindirectly. Therefore, regardless of the anatomical structure the cancer originates in or metastasizes to,
HNC-related diagnoses will inevitably involve therapies that require the management of oral or dental
sequelae.
AAOMS supports coverage for a dental or oral examination performed as part of a comprehensive
workup, as well as the medically necessary diagnostic and treatment services to eliminate an existingor potential oral or dental infection, prior to or contemporaneously with Medicare-covered
treatments for head and neck cancer whether primary or metastatic, regardless of where the cancer
originated. Specifically, AAOMS encourages CMS to consider expanding this policy to include
medically necessary dental services rendered post-radiation. AAOMS would be pleased to provide
additional information and/or guidance on the post radiation period, upon request.
Medication-related osteonecrosis of the jaw
Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication of antiresorptive and/or
antiangiogenic drug therapy. The medications associated with MRONJ, including bisphosphonates anddenosumab are commonly prescribed in the management of certain cancer-related conditions,metabolic bone diseases and osteoporosis14. The link between osteonecrosis of the jaw and these
medications has been long-studied, however proving causality of any medication-related complication ischallenging from an epidemiologic perspective. MRONJ is a rare entity, multifactorial in nature, andpatients with the same clinical presentation exist who have not been exposed to an antiresorptive
medication14.
To estimate the risk for medications associated with MRONJ, the primary parameter to be considered is
the therapeutic indication for treatment (e.g., malignancy or osteoporosis/osteopenia). The datasuggest that antiresorptive medications, such as bisphosphonates, denosumab and certain
antiangiogenics are associated with an increased risk for developing MRONJ14. The risk of MRONJ is
considerably higher in the malignancy group (<5%) than in the osteoporosis group (<0.05%). The current
literature reaffirms that the risk of MRONJ is significantly greater in cancer patients receiving
antiresorptive therapy compared to patients receiving antiresorptive therapy for osteoporosis14. We
note that current data are insufficient to identify other medications as risk factors for developing
MRONJ14. However, given the poly-pharmaceutical management of cancer patients, combined with thefact that cancer and immunosuppression are risk factors for MRONJ without exposure to antiresorptive
agents, identifying a single medication as being the etiologic agent for MRONJ seems unlikely in casereports or mini-case series.
The prevalence of MRONJ within populations exposed to the medications listed above has not beenfound to be statistically significant15 and, from a clinical standpoint, prevention of MRONJ is the gold
standard. However, for those patients diagnosed with MRONJ, management of the complication may
include both medical and surgical therapies14,15. Certain services, such as debridement of necrotic bone,sequestration or segmental or marginal resection of the jaws are historically considered for payment
under Medicare, when deemed medically necessary. However, other integrally related dental services
which may include, but are not limited to tooth extractions, alveoloplasty and removal of exostosis

generally are not. Inherently, current Medicare coverage limitations may work to exacerbate existing
barriers in accessing medically necessary and essential dental services in the treatment of osteonecrosis
and in the management of certain malignancies and metastatic bone disease.
As such, AAOMS encourages CMS to consider coverage for dental or oral examinations as part of acomprehensive workup, as well as the medically necessary diagnostic and treatment services toeliminate an oral or dental infection for Medicare beneficiaries diagnosed and being treated for
medication-related osteonecrosis of the jaw.
Total joint arthroplasty
Literature and scientific data on the effects of perioperative oral/dental health on patient outcomes
following total joint replacement is mixed. An industry-wide consensus on pre-surgical dental protocols
for orthopedic surgery has yet to be reached. However, AAOMS believes there is evidence that supports
the provision of perioperative dental examination and diagnostic and therapeutic services prior to total
joint replacement surgery, specifically primary total hip (THA) and knee (TKA) arthroplasty. According toYoung et al., the most consequential and costly postoperative complication is peri-prosthetic joint
infection, which continues to be the leading cause of chronic postsurgical pain and functional
limitation16. Peri-prosthetic joint infections increase burden on the health care system16. In fact, there isdata that shows peri-prosthetic joint infections nearly triple the cost of a total joint arthroplasty
procedure17.
The goal with peri-operative oral and dental management is to eliminate oral flora bacteremia that may
occur post joint replacement procedure that may colonize and infect the prosthetic joint. The
bacteremia can be spontaneous with patients that have advanced periodontal disease with large
bacterial bioload. Bacteremia can also be caused by invasive dentoalveolar procedures, such as tooth
extraction performed soon after the arthroplasty procedure. Therefore, identification of patients who
may fall into this category would be highly beneficial to prevent postoperative complications such as
infection. Such pre-operative diagnostic and therapeutic management would promote more rapid
healing and quicker rehabilitation, particularly if an unexpected dental procedure could be avoided in
the early postoperative phase. Of particular concern is the fact that oral health disparities
disproportionately affect members of racial or ethnic minority groups, most pronounced in populations
aged 65 and older16. In this age group, approximately 19 percent of patients are edentulous and morethan half present with moderate to severe periodontal disease16. Given the prevalence of total joint
arthroplasty in the Medicare population, this is significant.
As such, AAOMS encourages CMS to consider coverage for dental or oral examinations as part of acomprehensive workup, as well as the medically necessary diagnostic and treatment services toeliminate an oral or dental infection, prior to or contemporaneously with total joint arthroplasty
procedures.
Cardiac surgery
Similar to total joint arthroplasty procedures, there lacks consensus in the scientific literature on
prophylactic dental diagnostic and surgical treatment prior to cardiovascular surgery. The current
standard of care does not absolutely require dental evaluation prior to certain cardiac procedures,
which may in part be because such procedures are often more urgent or emergent, rather than elective.
Nonetheless, compelling scientific evidence exists to expand Medicare coverage to include dental/oral
examinations and necessary treatments to identify and eradicate dental/oral infection prior to, orcontemporaneously with certain cardiac procedures, as cited by CMS in the CY 2023 Medicare Physician
Fee Schedule Final Rule and finalized for CY 2023.
As expressed in previous comments, AAOMS supports CMS’ decision to allow Medicare Parts A and B
payment for a dental or oral examination performed as part of a comprehensive workup, as well as the
medically necessary diagnostic and treatment services to eliminate an oral or dental infection, prior to
or contemporaneously with cardiac valve replacement or valvuloplasty procedures.
Much of the scientific literature is inconclusive as to whether pre-operative dental treatments impact
postoperative surgical outcomes in cardiovascular surgery, including cardiac valve procedures18.
However, a systematic literature review by Cotti et al. found that, based on expert opinion there is
general agreement on the need for screening and treatment or oral/dental infections in patients who
are to undergo cardiac surgery, although no standardized clinical guidelines or protocols exist to outline
the screening process, in terms of both dental treatment options and timing of such procedures inrelation to the planned cardiac intervention19. The authors convened an expert panel (including
cardiologists, cardiac surgeons and dental specialists) to disseminate current data and establish aconsensus on early screening and resolution of dental or periodontal infections prior to cardiac
surgery19. This process resulted in standardized protocol for evaluating oral infections and dental
treatments for cardiac patients to be used in the interventional preparation phase by both dental andcardiac teams19. The authors note however, the lack of scientific evidence on the risk-to-benefit ratio forperioperative dental treatment in patients undergoing cardiovascular surgery19. Specifically, Cotti et al.
highlights the need for communication and care coordination between medical and dental providers
and care teams in determining the most appropriate treatment protocols for complex cardiac patients19. We find this systematic and detailed approach to perioperative dental treatment compelling in
relation to patients requiring cardiovascular surgery.
As such, AAOMS encourages CMS to consider extending Medicare coverage to include all
cardiovascular procedures, as the mitigation of perioperative and postoperative infection andcomplications is critical to ensure optimal surgical outcomes for all patients requiring invasive and/orinterventional cardiac procedures.

Recommendations of CDT©1 codes that describe medically necessary dental services
In general, the dental services being recommended for CMS’ consideration are those routinely
performed in the management of patients presenting with certain oral and maxillofacial pathology, suchas cellulitis and abscess of the face, mouth and/or neck; inflammatory conditions of the jaws including
osteoradionecrosis; osteomyelitis; drug-induced osteonecrosis; and all other oral sequelae of cancer
treatment. The recommended dental services also include those routinely performed for patientsrequiring total joint arthroplasty or cardiovascular surgery, when deemed clinically appropriate.
These recommendations are meant to provide a framework of the types of dental services that may beclinically advisable in relation to the above listed clinical scenarios. We wish to clarify that, not allservices may be appropriate in every circumstance. For example, a patient undergoing bisphosphonate

1

CDT© is a registered trademark of the American Dental Association

drug therapy may be at higher risk of developing osteonecrosis of the jaw, the onset of which may betriggered by invasive dentoalveolar surgery such as tooth extraction. Therefore, AAOMS believes thatclinical discretion and care coordination between the dental or oral health specialist and the medical
physician, as indicated by CMS is essential to ensure the clinical appropriateness of dental treatment inany given clinical scenario.
The following dental diagnostic and therapeutic services are recommended for CMS’ consideration of
Medicare payment for CY 2024 for the clinical scenarios previously described:•

Clinical oral evaluations, where essential for detection of dental/oral infection, as describedby CDT© codes D0140, D0150, D0160, D0180, D9310, D9410, and D9420
Many of the patients captured in the clinical scenarios thus far described have significant healthissues and often present with comorbidities that impact treatment and disease management.
Many of these evaluations are lengthy and require information and coordination between
several physicians or other qualified health care professionals.

•

Extractions and/or coronectomy, when indicated for eradication of dental/oral infection as
described by CDT© codes D7140, D7210, D7220, D7230, D7240, D7241, D7250, and D7251.
Extractions should be performed when indicated, specifically for teeth that cannot be managedwith non-surgical treatment. Medicare coverage considerations should include D7220, D7230
and D7240 as periodontal pockets can be involved in certain pathologies.

•

Alveoloplasty or ridge preparation procedures as described by CDT©^ codes D7310, D7311,
D7320 and D7321.
There are clinical scenarios in which an alveoloplasty is required in conjunction with extractions
as a preventative measure to reduce the risk of postoperative infection as well as to facilitate
future normal function with/without prosthesis placement. If alveolar anatomy is large and may
prevent intubation, this may be considered medically necessary. Specific to head and neck cancer
patients, such services may be required if the patient presents with chronic ulcerations of theoral cavity.

•

Excision of bone tissue, including exostosis and torus palatinus/mandibularis as described by
CDT© codes D7471, D7472, D7473 and D7485.
These services may also be considered preventive, in certain circumstances to reduce the risk of
postoperative infection. In other clinical scenarios, such services may be required to facilitate
prosthesis placement ensuring adequacy of function and nutrition, which is vital to healing fromany invasive dental surgical procedure.

•

Excision of benign soft tissue lesions as described by CDT© codes D7410, D7411, D7412.
If identified as part of a comprehensive oral examination or workup, these procedures may aid in
the determination of the disease process and facilitate appropriate treatment planning.

•

Excision of benign intra-osseous lesions as described by CDT© codes D7450, D7451, D7460,
D7461.
Similar to benign soft tissue lesions as outlined, there are clinical scenarios in which theseprocedures aid in the determination of the disease process, as well as facilitate appropriate
treatment planning.

•

Surgical incision and drainage procedures as described by CDT© codes D7510, D7511, D7520
and D7521.
Under certain circumstances, these procedures are medically necessary as an active infection
would preclude other dental surgical services, in addition to posing a significant threat to thepatient’s airway, depending on severity of the infection. Additionally, these procedures aid inestablishing a basis for patient health and prevent further bacterial dissemination through thebloodstream.

•

Periodontal and the partial ostectomy/sequestrectomy for removal of non-vital bone as
described by CDT© codes D4355 and D7550, respectively.
These procedures help to establish a healthy tissue baseline, as well as decrease the bioload ofbacteria in patients presenting with advanced periodontal disease.

•

Surgical removal of foreign body from mucosa, skin, subcutaneous alveolar tissue or themusculoskeletal system as described by CDT© codes D7530 and D7540.
Primarily, these procedures are required for the elimination or eradication of disease and/or
infection.

Thank you for your consideration of these recommendations and comments. Please contact Patricia
Serpico, Director, Health Policy, Quality & 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

______________
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