Source: https://www.medicareadvocacy.org/the-medicare-dental-exclusion-is-it-being-used-to-deny-vulnerable-beneficiaries-needed-care/
Timestamp: 2019-04-21 12:17:38+00:00

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The Medicare Dental Exclusion: Is it Being Used to Deny Vulnerable Beneficiaries Needed Care?
Government contractors administering Medicare benefits are routinely denying coverage to cancer patients for claims involving the surgical removal of decayed and infected teeth caused by an aggressive course of radiation treatment to the head and neck. The decayed and infected teeth, when left untreated, place these cancer patients at increased risk for infection, thereby decreasing rates of survival. These vulnerable patients are often too ill to challenge these systematic denials through the appeals process.
Radiation treatments are commonly prescribed for individuals who have oral, head, or neck cancer. A common result of aggressive radiation treatment to the head and neck is the destruction of salivary glands, a condition known as Xerostomia or dry mouth. Xerostomia leads to infections in the tooth root as well as at the gum line, causing teeth to literally crumble and break off at the root. Radiation treatment to the head and neck can also cause mucositis, altered salivary gland function, and a risk of mucosal infection. Mucositis is an “inflammation and ulceration of the oral mucosa,” which together with Xerostomia increases susceptibility to infection in cancer patients. Radiation treatment can also cause fibrosis and changes in the bone of teeth, jaws and surrounding tissues.
It is essential that a multidisciplinary approach be used for oral management of the cancer patient before, during, and after cancer treatment. A multidisciplinary approach is warranted because the medical complexity of these patients affects dental treatment planning, prioritization, and timing of dental care. In addition, selected cancer patients (e.g., status post treatment with high-dose head-and-neck radiation) are often at lifelong risk for serious complications such as osteoradionecrosis of the mandible. Thus, a multidisciplinary oncology team that includes oncologists, oncology nurses, and dental generalists and specialists as well as dental hygienists, social workers, dieticians, and related health professionals can often achieve highly effective preventive and therapeutic outcomes relative to oral complications in these patients.
An appeal filed recently by the Center For Medicare Advocacy in federal court, District of Connecticut, presents an opportunity for the court to review whether surgical treatment to a Medicare beneficiary’s teeth damaged by radiation therapy to the head and neck was 1) properly characterized by an Administrative Law Judge as a covered physician service medically reasonable and necessary as a part of an overall plan of care for cancer or 2) improperly characterized by the government contractor as excluded dental services. These competing interpretations depend upon how the specific treatment is characterized.
Characterization of the treatment as falling within the dental exclusion, 42 U.S.C. §1395y(a)(12), leaves a cancer patient without coverage for surgical removal of the decayed and infected teeth to prevent further infection and increase rates of survival. Characterizing the treatment as physician services supports coverage for medically reasonable and necessary treatment for the cancer patient pursuant to 42 U.S.C. §1395y(a)(1)(A). Federal regulations and Medicare policy support coverage for the surgical removal of decayed and infected teeth as a part of the cancer patient’s overall plan of care.
Medicare Part B pays for physicians’ services including diagnosis, surgery, consultations, and home, office and institutional call.
A dentist qualifies as a physician if he/she is a qualified doctor of dental surgery…[a]nd such services include…treatment of oral infections…in connection with covered services.
42 U.S.C. § 1395y (Emphasis added).
Mischaracterizing treatment for the consequence of radiation therapy, a covered medical service, as routine dental services without considering a cancer patient’s life-threatening condition as a whole is an improper interpretation of the Medicare statutory scheme. “The Medicare statute, remedial in nature, is to be broadly construed.” 42 U.S.C. §§1395 et seq. Hirsch v. Bowen, 655 F. Supp. 342 (S.D.N.Y., 1987) (citing Gartman v. Secretary of U.S. Department of Health and Human Services, 633 F. Supp. 671 (E.D.N.Y., 1986)).
Furthermore, “exclusions from coverage should be narrowly construed lest they inadvertently encompass the qualifications for benefits.” Westgard v Weinberger, 391 F.Supp. 1011, at 1019 (D.C.N.D., 1975) (citing Coe v. Secretary of Health, Educ. and Welfare, 502 F.2nd 1337, 1340 (4th Cir. 1974). See also Hibbs v. Winn, 542 U.S. 88, 101 (2004); The Wilderness Society v. U.S. Fish & Wildlife Service, 353 F.3d 1051, 1060-61 (9th Cir. 2003) (en banc) (“[i]t is … a fundamental canon that the words of a statute must be read in their context and with a view to their place in the overall statutory scheme”) (internal quotation marks and citation omitted).
The fact that the dental exclusion in the Medicare statute, 42 U.S.C. § 1395y(a)(12), is placed in the midst of a list of health services that are truly routine is evidence that this exclusion was also intended to apply to routine dental services rather than reasonable and necessary medical treatment for cancer patients that could directly affect patient survival.
In addition, the mischaracterization of treatment for the consequence of radiation therapy in cancer patients as an excluded dental service rather than as a covered physician service for the sole reason that it concerns “teeth” operates to deprive those patients of Medicare coverage for potentially life-saving ongoing treatment as a part of their overall plan of care.
These “extreme” dental and oral medical treatments fall within 42 U.S.C. §1395y(x) and should be covered by Medicare. The medical care is clearly not within the “routine” dental exception as anticipated by the law. Continuing to pretend otherwise denies very sick and vulnerable people coverage for medically necessary treatment they absolutely require, simply because it involves their mouths and teeth.
 Other cancer treatments, including certain chemotherapies and immune suppressing drugs used after bone marrow transplants, also cause devastating damage to the mouth, teeth and jaw. Currently, these oral injuries resulting from cancer treatments are rarely covered by Medicare.
 See e.g., The National Cancer Institute, “Complications of Chemotherapy and Head/Neck Radiation (PDQ) at http://www.cancer.gov/cancertopics/pdq/supportivecare/oralcomplications/HealthProfessional/page1 and Xerostomia, The Oral Cancer Foundation at http://www.oralcancerfoundation.org/complications/xerostomia.php.
 Pamela J. Hancock, Joel B. Epstein & Georgia Robins Sadler, Oral and Dental Management Related to Radiation Therapy for Head and Neck Cancer, 69 J. Can. Dental Assn. 585 (2003).
 National Cancer Institute PDQ, see footnote 2 above.

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