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ADA comments on CMS proposed rule to expand Medicare coverage of medically necessary conditions requiring dental services

Association largely supports draft rule; urges CMS to address questions related to cost and administration

The ADA is committed to addressing the oral health needs of older Americans and supports many of the components of a Centers for Medicare & Medicaid Services proposed rule to include dental benefits for Medicare beneficiaries under certain conditions deemed medically necessary.

In comments filed Sept. 2, the ADA told CMS it supports several of the rule's proposals to include a dental benefit for Medicare beneficiaries who are highly vulnerable in order to manage their medical condition and enhance their quality of life. The Association also shared concerns the ADA has about the cost and administration of the draft rule and urged CMS to clarify how a Medicare medically necessary benefit would be administered for dentistry to ensure that all beneficiaries can gain access to services they need.

Covering dental services under Medicare prior to certain medical or surgical procedures
ADA President Cesar R. Sabates and Executive Director Raymond A. Cohlmia, D.D.S., wrote that the ADA applauds CMS for including a dental benefit for Medicare beneficiaries who require the following:

- A dental or oral examination prior to renal organ transplant surgery.
- Reconstruction of a ridge when performed as a result of the surgical removal of a tumor. The ADA told CMS that this coverage should be available in all instances when the reconstruction of the ridge "is incident to" the surgical removal of a tumor, even if not coincident with the tumor removal.
- Stabilization of teeth when done in connection with the reduction of a jaw fracture or incident to another covered medical condition.
- Tooth extraction to prepare the jaw for radiation treatment of neoplastic disease.
CMS said it intends to expand access to these services by allowing a benefit in both the in-patient as well as the out-patient settings.

"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 to ensure the dentists in the out-patient setting can address the needs of these patients," according to the comments.

The ADA also said it supports including necessary dental treatments and diagnostics in Medicare for patients scheduled for organ transplants, cardiac valve replacements or valvuloplasty procedures to eliminate oral infections prior to surgery.

"We applaud CMS for specifying that services ancillary to dental procedures - such as X-rays, administration of anesthesia and use of the operating room - will be eligible for payment under the applicable payment system," the ADA wrote.

Tooth extractions should be 'last resort'
The ADA said that "while examination is the first step to identifying and eliminating dental disease, examination alone is not enough for improving health outcomes. Recovery, rehabilitation and maintenance of patients is equally important." The ADA also said that while eliminating infection prior to a procedure is critical, tooth extraction should be considered a last resort for treating disease. The Association urged CMS to consider covering other treatment options that are considered appropriate based on the clinical judgment of the care team.

"Medicare beneficiaries whose teeth can be reasonably preserved should be able to opt for more conservative approaches to care," the comments stated. "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."

Need for viable fee schedule
Regarding the proposal to use contractor pricing for dental services payable by Medicare, the ADA noted that there is no "widely accepted" Resource-Based Relative Value Scale for dental procedure codes represented by the Current Dental Terminology Code, the named Health Insurance Portability and Accountability Act standard for representing dental procedures on standard electronic transactions. The ADA urged CMS to collect and evaluate the most recent relevant data for over 700 CDT Codes in order to develop a viable fee schedule using that scale's methodology, which, to the Association's knowledge, has never been applied within dental claims.

Furthermore, the ADA noted that a dental practice typically has high costs of maintaining and running an office, including dental equipment, supplies, lab costs, staffing needs, anesthesia, sterilization and personal protective equipment. An appropriate weighting method "must be developed" in order for such a system to be used as an indexing method for a dental fee schedule.

"The ADA is willing and ready to assist CMS in accurately identifying a process whereby facility fees for care provided in out-patient settings can be adequately accounted for in any payment rate methodology that CMS will develop," the comments stated.

Dental care and other covered medical services
Regarding a proposal addressing clinical scenarios where dental services may be integral to the clinical success of other covered medical services, the ADA said the comment period did not allow a comprehensive review of the evidence on each of the cited medical conditions. The ADA did note that there is low certainty evidence that optimizing oral health may reduce the need for urgent pre-radiation treatment and dental treatment to potentially reduce the risk of osteoradionecrosis of the jaw in patients with head and neck cancer. The Association also said that regarding joint replacement therapy, evidence regarding a direct relationship between pre-operative dental assessment and improved outcomes following orthopedic surgery is lacking at this time.

"We look forward to reviewing evidence from other commenters demonstrating that the provision of dental services leads to improved healing, improved quality of surgery, and the reduced likelihood of readmission and/or surgical revisions," the ADA wrote.

Regarding coverage for dental services associated with stabilizing the dentition and/or repairing the jaw after accidental injury or trauma, ADA requests consideration of comprehensive coverage to enable reconstruction of post traumatic deformities of facial/jaw bones and soft tissue including restoration of form and function of the dentition.

"We appreciate the recognition that, under these circumstances, the dental services may not be provided prior to or contemporaneously with medical services," the ADA wrote. "We support CMS in proceeding with the proposal to allow payment for services furnished after the covered medical procedure or treatment when that is in the patient's best interest for clinical success for situations involving accidental injury or trauma."

Periodontal therapy and diabetes
Regarding CMS' question on whether certain dental services should be covered under Medicare for beneficiaries with diabetes, the ADA shared a 2022 Cochrane review that indicated periodontal therapy can improve glycemic control by a "clinically significant amount for people with diabetes" but noted to achieve these outcomes, "comprehensive and continuous dental care must be available."

The ADA requested that CMS conduct a cost analysis of expanding the medically necessary dental benefit to the population of people with diabetes and clarify the impact of such expansion given requirements around budget neutrality parameters in Medicare.

Coordinating care
Regarding a section soliciting feedback on how physicians, dentists and other practitioners should be compensated for time and resources spent coordinating care, the ADA said it is equally important to support dentists in the coordination required to manage these complex cases with their physician colleagues.

"It takes time and resources for health care providers to share relevant details about a patient's case, develop a mutually agreeable treatment plan and sequence, and provide follow-up or post-operative reports as necessary across health care services and specialties," the ADA wrote. "Without administrative - including financial - support in place for care coordination and case management, care teams may operate in a disjointed fashion, potentially compromising patient care and overall health outcomes."

The ADA also said that "meaningful integration" of medical and dental care for high-need patients will require not only health care provider coordination, but also the improvement of health IT systems. The Association encouraged CMS to conduct a review of current regulations and guidance regarding interoperability.

The ADA concluded its comments by saying, "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. 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."

Read the comments in full on the ADA website.

Follow all of the ADA's advocacy efforts at ADA.org/Advocacy .


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