Extending Medicare Coverage for Preventive and Other Services (2000) / Chapter Skim
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4 Medically Necessary Dental Services
4 Medically Necessary Dental Services
Pages 63-98
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From page 63... ...
. The 1965 legislation authorizing the program provided a narrow exception that payment could be made "in the case of inpatient hospital services in connection with the provision of dental services if the individual, because of his/her underlying medical condition and clinical status, or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services." As described in regulations and the program manuals used by the intermediaries and carriers who administer Medicare claims, the Health Care Financing Administration (HCFA)
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From page 64... ...
All dental services if incident to and an integral part of a covered procedure or service performed by the same person (Medicare Part B) Extractions prior to radiation and prior to oral examination if extractions occur (Medicare Part B)
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From page 65... ...
. It called for coverage of"dental services that are medically necessary as a direct result of, or will have a direct impact on, an underlying medical condition if the coverage of such services is cost-effective" (H.R.
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From page 66... ...
The concept that such care involves only care related to an "underlying medical condition" could suggest to some for example, that periodontal or other toothrelated infections are somehow different from infections elsewhere. More generally, such narrow definitions could imply that the mouth can be isolated from the rest of the body, a notion neither scientifically based nor constructive for individual or public healthy Thus, the remainder of this chapter refers to "medically necessary dental services," using quotation marks as a reminder of the term's specialized and restricted meaning in this discussion of Medicare coverage policy and, more generally, of the difficulty of precisely defining such care in most contexts.4 (Appendix C includes further examination of the concept of "medically necessary dental services.")
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From page 67... ...
The potential beneficial outcomes investigated include reduced mortality and morbidity due to more effective prevention or management of oral problems related to the five medical conditions or to complications of their treatment. More generally, dental care may improve patient knowledge of good oral health habits.
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From page 68... ...
TABLE 4-2 Summary of Dental Services Currently Covered and not Covered Under Medicare for Selected Diseases or Conditions Dental Services Disease or Currently Covered Dental Services not Currently Condition Under Medicare Covered Under Medicare Head and neck Extraction of teeth prior Oral examination if no extractions are cancer to radiation to be done prior to radiation Oral examination if Preventive care to reduce risk of ra extractions are to be diation caries (e.g., fluoride trays, performed supplemental topical fluoride) Treatment of radiation caries Lymphoma and Management of muco sitis, hemorrhage, and related side ef fects of underlying disease Oral examination prior to treatment Dental treatment to reduce risk of infection or eliminate infection prior to or following treatment Organ transplan- Management of infec- Oral examination for transplants other tation lion following trans- than kidney plantation Outpatient oral examination per Oral examination prior formed by a dentist prior to kidney to renal transplant transplant surgery on an inpa- Dental treatment to reduce risk of tient basis infection or eliminate infection for any transplantation prior to or fol lowing transplant Heart valve repair None or replacement Oral examination prior to repair or replacement Dental treatment to reduce risk of infection or eliminate infection prior to or following repair or replacement of valve
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From page 69... ...
One distinguishing feature of Figure 4-1 compared to the generic pyramid is that it requires a link between a nondental condition or treatment and either dental services or dental complications. The first tier of the pyramid refers accordingly to the relationship between the medical conditions listed earlier and oral health conditions.
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From page 70... ...
Cancers of the head and neck are more common among persons age 65 and older than among younger persons. Statistics often track invasive cancers of the oral cavity and pharynx and cancers of the larynx separately (SEER, 19991.6 These two categories of head and neck cancers account for approximately 2.6 and 1.6 percent, respectively, of all cancers.
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From page 71... ...
The oral side effects of cancer treatment that result from drugs, radiation, and surgery will often be managed by the physicians or surgeons overseeing treatment. For instance, they may modify the dose of anticancer drugs, take a "break" in the course of radiation therapy, or prescribe therapeutic mouthwashes 7Less regular care and later detection of cancers may partly explain the difference between black and white subpopulations in overall five-year survival rates for oral cavity and pharyngeal cancer (32 percent and 55 percent, respectively)
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From page 72... ...
Radiation therapy has additional, and specifically dental, implications that are examined next. Oral Health Problems Associated with Radiation Treatment of Cancers of the Head and Neck Because radiation therapy disrupts cell division in healthy tissue as well as in tumors)
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From page 73... ...
The rationale for covering such extractions was that tooth removal would preclude radiation-related caries and the possible later need for extractions that would increase the risk for ORN. In the 1970s, however, dentists began to experiment with aggressive toothsparing approaches to dental care before, during, and after radiation therapy for head and neck cancer.
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From page 74... ...
Patients in the tooth-preserving protocol also required fewer dental visits both before and after radiation therapy (Keys and McCasland, 1976~. ORN rates were historically low before and after the change in protocol, so the study did not demonstrate an effect on ORN.
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From page 75... ...
The costs to Medicare of adding coverage for certain tooth-preserving dental services for head and neck cancer patients and the possible offsetting savings are discussed later in this chapter. LEUKEMIA AND LYMPHOMA The first parts of this section discuss the general burden of disease and the oral health problems associated with leukemia and lymphoma and the treatment of these cancers.
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From page 76... ...
. Oral Health Problems and Leukemias Oral symptoms are a common reason for patients to seek care that leads to a diagnosis of leukemia.
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Oral Health Problems and Lymphomas Lymphoma patients, particularly Hodgkin's disease patients, are at increased risk for infections of all sorts. Non-Hodgkin's lymphoma patients can develop mouth ulcers.
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From page 78... ...
itself, chemotherapeutic treatment (including high-dose chemotherapy with bone marrow transplant) frequently induces oral health problems, in particular, mucositis and stomatitis (an inflammatory condition of the mouth)
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From page 79... ...
A recent study with no control group that tested the effect of not treating chronic dental disease prior to chemotherapy concluded that treatment for chronic problems could be safely postponed with little effect on the subsequent risk of acute dental disease (Toljanic et al., 1999~. It also concluded that a prechemotherapy oral examination was still needed to identify acute dental disease for treatment to prevent local exacerbations or systemic spread of infection These few studies of prechemotherapy dental treatment have involved mostly or entirely leukemia patients, who tend to receive aggressive, combination chemotherapy that is associated with more severe immunosuppression.
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From page 80... ...
. Oral Health Problems and Organ Transplantation The primary oral health issues for recipients of solid organ transplants are related to the drug therapy they must take to control graft rejection.
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From page 81... ...
. Some transplant centers will not operate on a patient with an active oral infection.
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From page 82... ...
. Effectiveness of Dental Care in Improving Health Outcomes for Organ Transplant Recipients As described in Appendix C, no direct evidence is available regarding the effect on survival of prevention, early detection, or treatment of oral health problems in transplant patients.
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HEART VALVE REPAIR OR REPLACEMENT Burden of Disease Heart valve disease may arise congenitally or develop later in life. The diseased valve is functionally impaired so that it cannot open properly, close sharply, or both.
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From page 84... ...
Oral Health Problems and Heart Valve Disease The oral cavity in general, and common oral infections in particular, can provide sources of organisms that may lead to heart valve infection, which in turn can lead to endocarditis. Clinicians have observed an association between oral disease and endocarditis, and Appendix C describes a causal model offering a possible explanation (after Drangsholt, 1998~.
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From page 85... ...
ESTIMATED COSTS TO MEDICARE OF EXTENDING COVERAGE The committee considered the likely costs of extending limited Medicare coverage for dental services provided in conjunction with surgery, chemotherapy, radiation, or pharmacological treatment for beneficiaries with the serious medical conditions reviewed above. Box 4-1 summarizes the assumptions and data on
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From page 86... ...
A more detailed presentation of the committee's cost estimates and the associated assumptions and data sources appears in Appendix E, which was prepared in consultation with the committee and background paper authors.
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From page 87... ...
The tables in Appendix E allow readers to vary some of the committee's assumptions and calculate alternative estimates The total net cost to Medicare of covering services for the five conditions examined for the five-year period from 2000 to 2004 is estimated to be $155.8
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From page 88... ...
The average number of dental visits per patient is based on the judgment of committee members and background paper authors. Except for head and neck cancer patients undergoing radiation therapy, visits were assumed only for patients with teeth.
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From page 89... ...
It has examined counseling to prevent dental and periodontal disease and stated that "counseling patients to visit a dental care provider on a regular basis, floss daily, brush their teeth daily with a fluoride containing toothpaste, and appropriately use fluoride for caries prevention and chemotherapeutic mouth rinses for plaque prevention is recommended based on evidence for risk reduction from these interventions" (USPSTF, 1996, p. 71 1~.~2 It also stated that "while examining the oral cavity, clinicians should be alert for obvious signs of oral disease" (p.
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From page 90... ...
Materials are available through the National Oral Health Information Clearinghouse, an information dissemination service of NIDCR. The campaign promotes medically necessary oral care prior to, during, and after cancer treatment to prevent or reduce the
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From page 91... ...
The committee found that standard clinical practice for head and neck cancer patients anticipating radiation to the jaw includes reliable identification of active and potential oral health problems for which effective management exists. Evidence is limited but supports the effectiveness of tooth-preserving regimens—especially the role of topical fluoride applications for head and neck cancer patients prior to and after radiation therapy.
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From page 92... ...
The committee found that standard clinical practice includes reliable identification of active and potential oral health problems for which effective dental and medical management exists. The committee found clinical experience to be suggestive that dental cleaning and restoration or extraction services are effective in reducing oral infection in leukemia patients as in other patients.
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From page 93... ...
Dental Care Effectiveness. The committee found that standard clinical practice includes reliable identification of active and potential oral health problems for which effective dental and medical management exists.
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From page 94... ...
The committee found that the standard clinical practice of preparing a patient to receive a transplant includes reliable identification of active and potential oral health problems for which effective dental and medical treatments exist. The committee located no published clinical trials providing direct evidence that dental care improves health outcomes for transplant recipients.
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From page 95... ...
In addition, the committee found no controlled studies demonstrating that dental procedures increase the incidence of endocarditis by introducing oral bacteria into the bloodstream, although the committee did find the model to be biologically plausible. Poor oral health may, however, produce bacteremia in the course of routine activities such as tooth brushing or chewing.
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From page 96... ...
Conclusions The committee concluded that the direct evidence to support coverage for "medically necessary dental services" varies depending on the medical condition to which dental services are related. Such evidence is, in general, lacking rather than negative or ambiguous.
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From page 97... ...
Again, patients would be referred to a dentist by their physician. The committee concluded that the evidence is insufficient to support positive or negative conclusions about dental services for patients with Iymphoma, organ transplants, and heart valve repair or replacement.
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From page 98... ...
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.
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