No Medicare Coverage of Much Needed Dental Care

     (CN) – Two Medicare beneficiaries whose illnesses caused dangerous tooth decay do not have a constitutional right to reimbursement of their dental care, the 9th Circuit ruled Thursday.
     Delores Berg suffers from Sjogren’s Syndrome, a disease that makes her unable to produce saliva. As a result, she lost her teeth, her gums deteriorated and her bite collapsed.
     Berg’s dentist recommended that she reconstruct her bite with a partial denture, several crowns and bridgework. She underwent these procedures in 2008 at a cost of $28,750.
     Thomas DiCecco lost his ability to produce saliva after he received a bone-marrow transplant to treat his leukemia. His tooth decay was so severe, it caused “certain teeth to just crack off,” and he had to use a feeding tube.
     His dentist performed restorative dental work in 2008, including filings and crowns, to reconstruct his mouth.
     Berg and DiCecco both claimed that their lack of saliva made them vulnerable to gum disease, which put them at risk of a life-threatening heart infection.
     Medicare broadly excludes coverage for most dental services, however, leaving beneficiaries like Berg and DiCecco unable to get their procedures reimbursed.
     A federal judge in Arizona affirmed denial of the pair’s claims, and the 9th Circuit likewise affirmed Friday.
     Though the relevant provisions of the Medicare Act were ambiguous, the secretary of Health and Human Services deserves deference for a reasonable interpretation of the Medicare Act, according to the ruling.
     “The services provided here could plausibly be viewed as either in connection with the care of teeth or with alleviating a symptom caused by a serious prior disease, namely Sjogren’s Syndrome or graft-versus-host disease,” Judge Ronald Gould wrote for a three-judge panel of the court based in Pasadena, Calif. “We can see that there are fair arguments on both sides of the issue and conclude that the statute is ambiguous.”
     Legislative history nevertheless supports the agency’s argument that Congress intended to limit dental coverage for patients who do not get dental work done the same day as a covered surgery, according to the ruling.
     “Appellants assert that the ‘favored classes’ of (1) patients who receive their dental services on the same day and from the same physician who provided a covered service, (2) patients who need extractions of teeth to prepare the jaw for radiation treatment, and (3) patients who require a comprehensive dental workup before a kidney transplant do not collectively demonstrate any logical principle. But each of these ‘favored classes’ describes patients with undoubtedly covered primary procedures who receive dental treatment in connection with those covered procedures,” Gould wrote.
     He added: “Appellants concede that the goal of limiting coverage is a legitimate governmental objective, and the distinction here is rationally related to that goal. Moreover, because their dental treatments were not ancillary to a covered procedure, appellants are not similarly situated to the ‘favored classes’ they cite.”

%d bloggers like this: