Stabenow, Peters Urge the Administration to Take Action to Improve Coverage of Oral and Dental Health for Seniors in Michigan

U.S. Senators Debbie Stabenow and Gary Peters as well as 26 of their colleagues yesterday called on the Department of Health and Human Services to take action to improve Medicare coverage of medically necessary oral and dental treatment. Providing seniors in Michigan traditional Medicare coverage for medically necessary oral and dental care will improve oral health and overall wellness as well as potentially reduce costs to the Medicare program.

“We urge CMS to use existing regulatory authority, consistent with past precedent, to make available traditional Medicare coverage for those beneficiaries requiring medically necessary oral and dental care,” wrote the senators. “We look forward to working with you to save lives, improve health outcomes, and reduce Medicare costs by avoiding medical complications through delivery of medically necessary oral and dental treatment.”

The text of the letter may be found below. 

September 20, 2018

The Honorable Alex Azar                                                       The Honorable Seema Verma

Secretary                                                                                 Administrator

U.S. Department of Health & Human Services               Centers for Medicare & Medicaid Services

200 Independence Avenue SW                                          7500 Security Blvd.

Washington, DC 20201                                                        Baltimore, MD 21244

Dear Secretary Azar and Administrator Verma:

As policymakers, we have a responsibility to find health care solutions that save lives, improve outcomes and reduce costs. Given oral health’s proven connection to overall wellness, improving Medicare coverage of medically necessary oral and dental health will accomplish these objectives. Therefore, we write to request that the Centers for Medicare and Medicaid Services (CMS) use existing regulatory authority to provide traditional Medicare coverage of medically necessary oral and dental treatment. 

It is estimated that two thirds of all Medicare beneficiaries have periodontal disease. Unfortunately, many Medicare beneficiaries face significant health risks because they do not have access to medically necessary oral and dental treatment.  Too often, the lack of such treatment is exacerbating beneficiaries’ health conditions and, thus, increasing Medicare’s costs for treating their illnesses.  In such instances, providing medically necessary oral and dental treatment has the potential to reduce costs to the Medicare program by improving patient outcomes. For example, insurance companies have achieved significant medical savings by providing coverage for the treatment of periodontal disease for individuals with heart disease and diabetes. An Avalere Health report estimates that such coverage could achieve net savings for the traditional Medicare program of $63.5 billion over ten years.

As you know, Section 1862(a)(12) of the Social Security Act excludes Medicare coverage of routine dental services.  However, that provision does not prohibit the CMS from authorizing coverage when the treatment is medically necessary.  In crafting the list of Medicare coverage exclusions, Congress’ intent was to ensure Medicare funds would not be used pay for items and services that beneficiaries utilize outside of the context of medical illness and injury – in other words, items and services that are not medically necessary.  Indeed, Senate Report No. 89-404 (1965) expressly provides that payment can be made when there is appropriate medical justification, such as when the item or service is necessary for the diagnosis or treatment of a Medicare-covered disease, illness, or injury.

There is ample precedent for CMS’ use of this discretionary authority.  For example, Medicare policy provides for the coverage of medically necessary podiatry services, even as routine foot care is expressly excluded from coverage by the Medicare statute.  In similar fashion, we believe CMS should use its authority to extend traditional Medicare coverage to oral and dental treatment that is medically necessary for the treatment of Medicare-covered diseases, illnesses, and injuries.  Below are a few representative examples that illustrate the clinical and fiscal utility of such coverage:

• Emergency department visits and hospitalizations for medical problems in which oral/dental bacteria are an underlying cause, such as an infected cardiac or orthopedic prosthesis.
• Parkinson’s Disease, in which dentally sourced bacteria can contribute to aspiration pneumonia, and/or infection of medical devices, such as deep brain neurostimulators and artificial knees and hips.
• Bacterial endocarditis and worsened stroke outcomes due to an increased inflammatory burden caused by unresolved dental infections.
• Multiple sclerosis, in which oral/dental bacteria can cause serious infection for patients taking pharmaceuticals that suppress the immune system, such disease-modifying therapeutic drugs.
• Delay or interruption of treatment for various gastrointestinal diseases, including certain liver and inflammatory bowel diseases (IBD) due to untreated oral/dental disease.
• Rheumatologic disease, for which patients must often take medication that suppress their immune systems, thereby making them more susceptible to infection from untreated oral/dental disease.
• Diabetes management compromised by periodontal infections, which increases the risk of kidney disease and failure, vascular dementia, visual degradation, podiatric complications, cardiac disease and stroke.
• Arthroplasty of the hip and knee, which cannot safely proceed without prior resolution of oral/dental disease because of the risk of post-operative infection.
• Cancer treatment, in which leukopenia from chemotherapy increases the risk of dentally sourced bacteria causing sepsis or other serious complications.
• Organ transplantation, for which dental infections risk serious complications because patients are pharmacologically immunosuppressed to prevent rejection.
• Metastatic lung, breast, prostate and colon cancers, multiple myeloma, and hypercalcemia, which often involve bisphosphonate drugs, for which dental health is advised to prevent osteonecrosis of the jaw.
• Implanted heart valves, arterial stents, and stent grafts, which are at risk of infection and costly complications due to bacteria sourced from dental infections.

For these reasons, we urge CMS to use existing regulatory authority, consistent with past precedent, to make available traditional Medicare coverage for those beneficiaries requiring medically necessary oral and dental care. 

Thank you for your attention to this matter.  We look forward to working with you to save lives, improve health outcomes, and reduce Medicare costs by avoiding medical complications through delivery of medically necessary oral and dental treatment.