CMA Offers Guidance on Obtaining Medicare Coverage for Non-Routine Dental Services

The Center for Medicare Advocacy has just issued a report discussing the circumstances in which Medicare may be liable for dental services. The report concludes: “The likelihood of obtaining Medicare coverage for non-routine dental care can be increased by taking certain steps. First, a treatment plan established at the outset by the primary physician providing covered medical services should include provision for ancillary dental care. As dental services are needed, the physician should record the fact that they are incident to and necessary for the patient’s primary treatment, and prescribe the specific dental services. This will take such dental services out of the exclusion for routine care, and show that they are “incident to and an integral part of” a covered course of treatment. In order to obtain a successful decision, it may be necessary for the beneficiary to go through a number of unsuccessful lower levels of administrative appeal before reaching the ALJ or federal court levels. At these higher levels of appeal, the beneficiary or her advocate will have an opportunity to overcome the presumption that Medicare never covers dental services. Testimony and medical records from the beneficiary’s physicians should be presented to show that the dental services were ordered and supervised by them as part of the claimant’s covered treatment. Legal arguments can be made that 1) the controlling Medicare statute, as shown by its legislative history, excludes only coverage of routine dental services; 2) the manual requirement that services be “incident to and an integral part of” covered services was met; or if not met, 3) the interpretations of the statute in the manual are too inconsistent and unreasonable to be given deference.”

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