ADA supports Medicare dental changes but wants clarity

The ADA supports the U.S. Centers for Medicare and Medicaid Services' (CMS) proposal to expand coverage of medically necessary conditions requiring dental services, but it wants the agency to address issues related to the administration and reimbursement of the benefits.

In a September 2 letter to the CMS, the ADA supports several suggestions, including coverage for cardiac valve replacements and organ transplants, that are outlined in the proposed rule. However, the association remains concerned about costs and their management if dental services are made available to vulnerable Medicare beneficiaries.

"While the ADA appreciates the value of such expanded access to care for Medicare beneficiaries, the ADA would like clarification regarding certain claims and payment policies in order to ensure the dentists in the outpatient setting can address the needs of these patients," ADA President Dr. Cesar Sabates and Executive Director Dr. Raymond Cohlmia wrote in its letter to the CMS.

In 2021, the ADA actively opposed a different proposal that would have expanded Medicare participants' access to dental services through Medicare Part B. At the time, the ADA claimed it didn't serve the needs of patients or dentists and therefore encouraged its 160,000-plus membership to object to the proposal. Currently, there are about 24 million Medicare beneficiaries who do not have dental coverage.

Backstory of new changes

On July 7, the CMS announced proposed changes for payments under the Calendar Year 2023 Physician Fee Schedule rule and other Medicare Part B issues that would include Medicare paying for dental exams and treatment preceding organ transplants. If approved, it would be effective as early as January 1, 2023. The proposed rule change was announced weeks after more than 100 U.S. lawmakers asked the CMS to broaden the definition of medically necessary dental coverage.

Additionally, legislators asked the CMS to expand services to "all medically necessary situations," including hospitalizations for conditions that stem from oral bacteria, such as an infected orthopedic prosthesis. Lawmakers also wrote that dental service should be considered medically necessary for Medicare beneficiaries with conditions that can be worsened by oral bacteria and infection, including heart diseases, diabetes, multiple sclerosis, and cancer.

Tuesday, September 6, is the last day for the public to comment on what other medical conditions, such as cancer treatment or joint replacement surgeries, warrant coverage under the U.S. healthcare program for dental services.

ADA gives thumbs-up on specific procedures

In the September letter, the ADA praised the agency for proposing a dental benefit for beneficiaries who need the following:

• Dental or oral exams as part of a comprehensive workup prior to a renal organ transplant
• Reconstruction of a ridge when it is performed due to and at the same time as the surgical removal of a tumor
• Wiring of teeth when done in connection with the reduction of a jaw fracture
• A dental splint when performed in conjunction with treatment that is determined to be a covered medical condition
• Extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease

Furthermore, the ADA wrote that the coverage for reconstruction of a ridge should be available in all instances when the reconstruction of the ridge "is incident to" the surgical removal of a tumor and that the reconstruction does not alone return the patient to a condition of health.

"Without the subsequent replacement of teeth on that ridge to facilitate the intake of nutrition, phonetics necessary for communication and social interaction, the patient is left crippled after the surgical tumor removal," the ADA wrote.

Moreover, the ADA supports including needed dental care in Medicare for patients who are scheduled for organ transplants, cardiac valve replacements, or valvuloplasty procedures to eliminate oral infections before surgery.

Though eliminating infection prior to a procedure is critical, tooth extraction should be considered a last resort. Instead, the ADA encouraged the CMS to cover other conservative treatments that are considered appropriate based on the care team.

"To this end, we urge CMS to consider coverage of comprehensive services beyond 'elimination of infection' prior to medical/surgical procedure. Moreover, even when extraction is the best treatment, extraction without subsequent replacement of the extracted teeth leaves the patient disabled."

Jaw osteoradionecrosis, diabetes, more

Though the comment period did not provide the ADA time for a comprehensive review of all the literature concerning all conditions recommended for Medicare coverage, the association noted that there is low certainty evidence that optimizing oral health may reduce the need for urgent preradiation treatment and dental treatment to possibly cut the risk of osteoradionecrosis of the jaw in patients with head and neck cancer. Regarding joint replacement therapy, the evidence is lacking in terms of a direct relationship between preoperative dental assessment and improved outcomes following orthopedic surgery, according to the letter.

As for periodontal care and diabetes, the ADA supports coverage for this condition. However, since complete and continuous dental care needs to be available to improve the glycemic control of patients with diabetes, the ADA asked the agency to conduct a cost analysis and clarify the impact of such expansion given requirements around budget neutrality parameters in Medicare.

Dentistry-centric fee schedule and care coordination

CMS' proposal calls for the use of contractor pricing for dental services payable by Medicare. However, the ADA states that there is no universally accepted resource-based relative value scale for dental procedure codes represented by the current dental terminology code.

Therefore, the ADA encourages the CMS to collect and evaluate recent relevant data to develop a viable fee schedule for dental claims, as well as a weighting method that takes into account the costs of operating an office, including dental equipment, lab costs, staffing needs, and anesthesia.

Finally, the ADA states that it needs administrative support, including financial, to manage cases and coordinate care with other doctors and specialists. The association urged the CMS to conduct a review of current interoperability regulations and guidance, because expanding access will require the "meaningful" integration of health IT systems.

"In summary, the ADA supports a scope of services necessary to complete a dentist prescribed treatment plan for the targeted population, who are highly vulnerable, to enable management of their medical condition and enhance their quality of life," they wrote. "We urge CMS to clarify the issues we have raised in these comments to ensure that Medicare beneficiaries can gain access to services they need in an outpatient setting."