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Extending Medicare Coverage for Preventive and Other Services
als. The committee’s conclusion does not negate the value of clinical judgment in selecting appropriate individual patients for such interventions.
Although the evidence base for “medically necessary dental services” is mixed and frequently based on weak research designs, the committee is concerned about interpretations of the current law that could preclude HCFA from approving further coverage exceptions for dental services to identify and eliminate oral infections or potential sources of infection for immunocompromised high-risk patients. As noted earlier, widely accepted clinical protocols for identifying and eliminating all infections and potential sources of infection before transplantation are based on biological principles and clinical experience, not controlled trials. The committee is also concerned about legislative proposals requiring that “medically necessary dental services” produce savings that exceed the direct costs of care. As described in Chapter 5, even elimination of the three-year limit on coverage of immunosuppressive drugs—drugs that clearly improve outcomes for transplant recipients—is unlikely to meet this standard.
Given the scientific and therapeutic advances since the creation of Medicare in 1965 and the concerns about current coverage interpretations, the committee concludes that it is reasonable for Congress to update the statutory language relating to coverage of dental services so that it would clearly cover dental care that is effective in preventing or reducing oral and systemic complications associated with serious medical conditions and their treatment. Specifically, the committee suggests that Congress should direct the Health Care Financing Administration (with assistance as appropriate from the Agency for Health Care Policy and Research and the National Institutes of Health) to develop recommendations—on a condition-by-condition basis—for coverage of dental services needed in conjunction with surgery, chemotherapy, radiation, or pharmacological treatment for a life-threatening medical condition. The phrase “in conjunction with” would allow HCFA to limit the window of coverage to a specified period before or after surgery or other treatment but would not require that the services be provided at the same time as or as an immediate part of a surgical or other procedure. This minimal revision in the 1965 exclusion of coverage for dental services would not alter Medicare’s basic focus on treatment of acute illness or injury.
If Medicare were to cover “medically necessary dental services” for some or all of the medical conditions reported here, it is uncertain how many beneficiaries in each category would avail themselves of this benefit. The referral for “medically necessary dental care” would likely come from the treating physician at the time of diagnosis or planning of the medical therapy. The patient’s physician would in this way serve as a gatekeeper for this benefit, especially among patients who are not under regular dental care. In addition, physicians would continue to manage many oral problems themselves, for example, by prescribing antibiotics and therapeutic rinses.