When clients ask me about Medicare and dental coverage, I tell them Medicare covers dental services in certain situations. But that was probably wrong information.
I got an email from the Center for Medicare Advocacy which sued CMS (Medicare) on behalf of a man who was denied coverage for dental care that was clearly connected to a medical problem. Here’s the story:
Henry Lodge was diagnosed with life-threatening head and neck squamous cell cancer in 1996. His treatment involved radical dissection of his neck, implantation of radioactive seeds in the base of his tongue, and 30 days of direct beam radiation. The surgery and the scarring from radiation permanently impaired his ability to speak and swallow, and destroyed his salivary glands, which caused rampant tooth decay and painful oral ulcers. Years later, when the trajectory of these combined problems led to severe weight loss and poor nutrition, his oncology team decided that he required tooth extractions and implant surgery to restore his ability to eat and prevent further deterioration of his jawbone. Hyperbaric oxygen (HBO) therapy prior to and after the extractions was needed to ensure proper wound healing. Medicare covered the HBO therapy but denied payment for the extractions and implants, stating that they fell under Medicare’s exclusion for dental services.
The Center for Medicare Advocacy (the Center) represented Mr. Lodge in his agency appeal. At the third stage of review, an Administrative Law Judge (ALJ) found that the dental procedures were “not routine or of the type which were meant to be excluded by the statute”, but instead “were to restore function to the Appellant’s jaw, and are, in a sense, a continuation of the treatment for the oral cancer”, which had “affected the Appellant’s overall health and ability to eat adequate nutrition.”
But CMS (Medicare) appealed the decision and got it overturned. Meaning, poor Mr. Lodge would not get his dental care paid for by Medicare. Wow, that seems heartless.
The truth is that Medicare and dental care do not go together.
Most of my clients are concerned about dental care like cleaning, crowns, and root canals. I can confidently tell them that Medicare does not cover standard dental care – but I thought Medicare would cover some dental services that are clearly connected to medical issues like Mr. Lodge had. But the lawsuit that was won – and then lost – shows that Medicare is heartless when it comes to anything to do with your teeth.
How sad that is for Mr. Lodge and other people whose health and well-being depend on their teeth.