(Medicare Benefit Policy Manual)

There are some other instances where medical services necessary to diagnose and treat the individuals underlying medical condition may require the performance of certain dental services and the dental exclusion may not apply. Dental services that are inextricably linked to, and substantially related and integral to the clinical success of, certain covered medical services are not excluded. Such non- excluded dental services could include dental and oral examinations as well as medically necessary diagnostic and treatment services to eliminate an oral or dental infection. We note that the necessary treatment to eradicate an infection may not include the totality of recommended dental services for a given patient. For example, if an infected tooth is identified in a patient requiring  an organ transplant, cardiac valve replacement, or valvuloplasty procedure, the necessary treatment would be to eradicate the infection, which could result in the tooth being extracted. Additional dental services, such as a dental implant or crown, may not be considered immediately necessary to eliminate or eradicate the infection or its source prior to surgery. Therefore, such additional services would not be inextricably linked to, and substantially related and integral to the clinical success of, the or gan transplant, cardiac valve replacement, or valvuloplasty services. As such, no Medicare payment would be made for the additional services that are not immediately necessary prior to surgery to eliminate or eradicate the infection.   Payment may be made under Medicare Parts A and B for dental services, prior to or, in certain circumstances, contemporaneously with, certain covered medical services furnished in the inpatient or outpatient setting. Scenarios in which Medicare payment for dental services is not excluded include, but are not limited to, the examples below.   EXAMPLE 1:   Dental or oral examination performed as part of a comprehensive workup in either the inpatient or outpatient setting prior to Medicare -covered organ transplant, cardiac valve replacement, or valvuloplasty procedures; and, medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to, or contemporaneously with, the organ transplant, cardiac valve replacement, or valvuloplasty procedure. For purposes of this manual only, hematopoietic stem cell and bone marrow transpl ants have a similar risk of infection to organ transplants, and an oral examination and subsequent necessary diagnostic and treatment services, performed in either the inpatient or outpatient setting would be payable under this example. (The term organ tr ansplant may not be considered to include bone marrow or hematopoietic stem cell transplants in all contexts. These services are not considered organs for purposes of the definition of organs in 42 CFR 486.302 or Medicare payment policies for organ procur ement organizations.)   EXAMPLE 2:   The reconstruction of a ridge performed as a result of and at the same time as the surgical removal of a tumor.  The reconstruction of a ridge performed primarily to prepare the mouth for dentures is a noncovered procedure.   EXAMPLE 3:   The stabilization or immobilization of teeth in connection with the reduction of a jaw fracture, and dental splints only when used in conjunction with covered treatment of a covered medical condition such as dislocated jaw joints.   EXAMPLE 4:   The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.    See Pub 100- 01, the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, Definitions for provisions applicable to doctors of dental surgery or dental medicine.   CMS makes payment for covered dental services furnished by a physician, including a doctor of dental medicine or dental surgery, or a non- physician practitioner in accordance with state law and scope of practice in the state where the service is furnished.      Medicare Part A and Part B payment is made for dental services that are inextricably linked to, and substantially related and integral to the clinical success of, certain covered medical services. Integration between the health care professionals furnishing dental and other covered services is a key component in assessing whether dental services are inextricably linked to, and substantially related and integral to the clinical success of, other covered medical services. This integration could take the form of a referral or other exchange of information between the physicians, non-physician practitioners, or other practitioners involved in the delivery of dental and other covered medical services.   This coordination should occur between the health care professionals furnishing the dental and other covered services regardless of whether both individuals are affiliated with or employed by the same entity. If there is no exchange of information, or integration, between the health care professionals regarding the dental services, then there would not be an inextricable link between the dental and covered medical services within the meaning of our regulation a t  411.15(i)(3). This is because the professio nals would not have the necessary information to decide that the dental service(s) is inextricably linked to a covered medical service, and therefore, not subject to the statutory payment exclusion under section 1862(a)(12) of the Act.   Payment may also be made for covered dental services and supplies furnished incident to the professional services of the billing physician or practitioner by auxiliary personnel. For example, services performed by a dental technician, dental hygienist, dental therapist, or registered nurse who is under the direct supervision of the physician, including a dentist, are covered if the services meet the requirements for incident to services as described in 42 CFR  410.26.  Ancillary services and supplies furnished incident to covered dental services are also not excluded, and Medicare payment may be made under Part A or Part B, as applicable, regardless of whether the service is performed in the inpatient or outpatient setting, including, but not limited to the administration of anesthesia, diagnostic x -rays, use of operating room, and other related, otherwise covered procedures.   No payment is made for dental services that may be inextricably linked to, and substantially related and integral to the clinical success of other non -covered services.  Such services remain subject to the statutory exclusion at  1862(a)(12) for items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. More specifically, dental services inextricably linked to a non- covered medical service(s) are not covered or payable. For example, an alveoplasty (the surgical improvement of the shape and condition of the alveolar process) and frenectomy are excluded from coverage when either of these procedures is performed in connection with an excluded service, e.g., the preparation of the mouth for dentures. Similarly, with rare exception, the removal of a torus palatinus (a bony protuberance of the hard palate) is performed in connection with an excluded service, i.e., the preparation of the mouth for dentures. Under such circumstances, Medicare does not pay for this procedure.   MACs have the flexibility to determine on a claim-by- claim basis whether a patients circumstances do or do not fit within the terms of the statutory preclusion or exceptions specified in section 1862(a)(12) of the Act and our regulation at 42 CFR  411.15(i).  These policies do not prevent a MAC from making a determination that payment can be made for dental services in other circumstances under which the dental services are inextricably linked to, and substantially related and integral to the clinical suc cess of, certain covered medical services, but are not specifically addressed in final rules, manual provisions, and the finalized amendments to 411.15(i).   150.1 - Treatment of Temporomandibular Joint (TMJ) Syndrome  (Rev. 1, 10-01-03) PASS memo Read.014  There are a wide variety of conditions that can be characterized as TMJ, and an equally wide variety of methods for treating these conditions.  Many of the procedures fall within the Medicare programs statutory exclusion that prohibits payment for items and services that have not been demonstrated to be reasonable and necessary for the diagnosis and treatment of illness or injury ( 1862(a)(1) of the Act).  Other services and appliances used to treat TMJ fall within the Medicare programs statutory exclusion at 1862(a)(12), which prohibits payment for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.... For these reasons, a diagnosis of TMJ on a claim is insufficient.  The actual condition or symptom must be determined.  160 - Clinical Psychologist Services (Rev. 51, Issued: 06-23- 06, Effective: 01 -01-05, Implementation: 09-21-06)  A.  Clinical Psychologist (CP) Defined   To qualify as a clinical psychologist (CP), a practitioner must meet the following requirements:   Hold a doctoral degree in psychology;  Be licensed or certified, on the basis of the doctoral degree in psychology, by the State in which he or she practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals.  B.  Qualified Clinical Psychologist Services Defined   Effective July 1, 1990, the diagnostic and therapeutic services of CPs and services and supplies furnished incident to such services are covered as the services furnished by a physician or as incident to physicians services are covered.  However, the CP must be legally authorized to perform the services under applicable licensure laws of the State in which they are furnished.  C.  Types of Clinical Psychologist Services That May Be Covered  Diagnostic and therapeutic services that the CP is legally authorized to perform in accordance with State law and/or regulation.  A/B MACs (B) pay all qualified CPs based on the physician fee schedule for the diagnostic and therapeutic services.  (Psychological tests by practitioners who do not meet the requirements for a CP may be covered under the provisions for diagnostic tests as described in 80.2.  Services and supplies furnished incident to a CPs services are covered if the requirements that apply to services incident to a physicians services, as described in 60 are met.  These services must be:    Mental health services that are commonly furnished in CPs offices;   An integral, although incidental, part of professional services performed by the CP;   Performed under the direct personal supervision of the CP; i.e., the CP must be physically present and immediately available;    Furnished without charge or included in the CPs bill; and   Performed by an employee of the CP (or an employee of the legal entity that employs the supervising CP) under the common law control test of the Act, as set forth in 20 CFR 404.1007 and RS 2101.020 of the Retirement and Survivors Insurance part of the Social Security Program Operations Manual System.   Diagnostic psychological testing services when furnished under the general supervision of a CP.  A/B MACs (B) are required to familiarize themselves with appropriate State laws and/or regulations governing a CPs scope of practice.  D.  Noncovered Services   The services of CPs are not covered if the service is otherwise excluded from Medicare coverage even though a clinical psychologist is authorized by State law to perform them.  For example, 1862(a)(1)(A)  of the Act excludes from coverage services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.  Therefore, even though the services are authorized by State law, the services of a CP that are determined to be not reasonable and necessary are not covered.  Additionally, any therapeutic services that are billed by CPs under CPT psychotherapy codes that include medical evaluation and management services are not  covered.   E.  Requirement for Consultation   When applying for a Medicare provider number, a CP must submit to the A/B MAC (B) a signed Medicare provider/supplier enrollment form that indicates an agreement to the effect that, contingent upon the patients consent, the CP will attempt to consult with the patients attending or primary care physician in accordance with accepted professional ethical norms, taking into consideration patient confidentiality.  If the patient assents to the consultation, the CP must attempt to consult with the patients physician within a reasonable time after receiving the consent.  If the CPs attempts to consult directly with the physician are not successful, the CP must notify the physician within a reasonable time that he or she is furnishing services to the patient.  Additionally, the CP must document, in the patients medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician.  The only exception to the consultation requirement for CPs is in cases where the patients primary care or attending physician refers the patient to the CP. Also, neither a CP nor a primary care nor attending physician may bill Medicare or the patient for this required consultation.  F.  Outpatient Mental Health Services Limitation   All covered therapeutic services furnished by qualified CPs are subject to the outpatient mental health services limitation in Pub 100 -01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Deductibles, Coinsurance Amounts, and Payment Limitations, 30, (i.e., only 62 1/2 percent of expenses for these services are considered incurred expenses for Medicare purposes).  The limitation does not apply to diagnostic services.   G.  Assignment Requirement  Assignment is required.  170 - Clinical Social Worker (CSW) Services (Rev. 1, 10-01-03) B3-2152  See the Medicare Claims Processing Manual Chapter 12, Physician/Nonphysician Practitioners, 150, Clinical Social Worker Services, for payment requirements.  A.  Clinical Social Worker Defined   Section 1861(hh) of the Act defines a clinical social worker as an individual who:    Possesses a masters or doctors degree in social work;