Under Medicaid, dental benefits exist, but the coverage is limited. This limited coverage makes it important for advocates to understand the exceptions to different coverage limitations. By understanding the nuances of the benefit, advocates can help get their clients the coverage they need.

NEWS FLASH SEPTEMBER 2018:

In August, 2018, The Legal Aid Society and Willkie Farr & Gallagher filed Ciaramella v. Zucker (18-cv-06945) to challenge the New York State Department of Health’s rules preventing Medicaid coverage for replacement dentures within 8 years from initial placement and the ban on Medicaid coverage for dental implants.  See article in New York Times, August 2, 2018, “Lack of Dental Coverage Hampers Medicaid Recipients, Suit Says.” In response, DOH will be implementing changes to the dental manual to cover dental implants when medically necessary and to change the rules for replacement dentures. These changes, described below and in this document, will take effect on November 12, 2018.  The new rule on replacement dentures imposes new documentation requirements and will be a step backward for some.

Legal Aid Society asks you to let them know if you are working with Medicaid-eligible individuals who require dental implants or replacement dentures, including those whose care may not be covered based on the revised policy.  They also want to speak with Medicaid-eligible individuals who require any other dental treatments that are not covered by Medicaid including root canals, immediate dentures, osseous surgery.   Contact: Legal Aid Society Health Hotline  (212) 577-3575 or email

Revised policy effective November 12, 2018 – click on these links:  

VI. Prosthodontics –  Full and /or partial dentures

 

VIII. Implant Services

 

WHAT DENTAL SERVICES ARE COVERED UNDER MEDICAID?

THE FOLLOWING DENTAL SERVICES ARE EXCLUDED UNDER MEDICAID AND WILL NOT BE REIMBURSED

  • Dental implants and related services (BUT THIS WILL CHANGE NOV. 12, 2018 to the following policy: 

    VIII. Implant Services (revised Nov. 12, 2018

    Dental implants will be covered by Medicaid when medically necessary. Prior approval requests for implants must have supporting documentation from the patient’s physician and dentist. A letter from the patient’s physician must explain how implants will alleviate the patient’s medical condition. A letter from the patient’s dentist must explain why other covered functional alternatives for prosthetic replacement will not correct the patient’s dental condition and why the patient requires implants. Other supporting documentation for the request may be submitted including x-rays. Procedure codes and billing guidelines will follow. 

  • Fixed bridgework, except for cleft palate stabilization, or when a removable prosthesis would be contraindicated;

  • Immediate full or partial dentures;

  • Molar root canal therapy for beneficiaries 21 years of age and over, except when extraction would be medically contraindicated or the tooth is a critical abutment for an existing serviceable prosthesis provided by the NYS Medicaid program;

  • Crown lengthening;

  • Replacement of partial or full dentures prior to required time periods unless appropriately documented and justified as stated in the Manual — see changes  effective Nov. 12, 2018

  • Dental work for cosmetic reasons or because of the personal preference of the recipient or provider;

  • Experimental procedures

WHAT IF MEDICAID DENIES THE CLAIM?

  • Although Medicaid Dental is limited to essential services, if you believe your claim has been improperly denied, you may request a plan appeal (in Medicaid managed care) or a Fair Hearing.

RELEVANT REGULATIONS

FAIR HEARINGS

COMMON ISSUES

The Fair Hearings described below were decided based on the OLD denture Policy, which expires Nov. 11, 2018.

  • Disease or extensive physiological change can include additional lost teeth, especially if an abutment for the current denture is lost or damaged.  See, e.g., FH #6254420Y. (available here

  • If a recipient’s health would be adversely affected by the absence of a prosthetic replacement, and the recipient could successfully wear a prosthetic replacement, such a replacement will be considered. In the event that the recipient has a record of not successfully wearing prosthetic replacements in the past, or has gone an extended period of time (three years or longer) without wearing a prosthetic replacement, the prognosis is poor. Mitigating factors surrounding these circumstances should be included with the prior approval request.

  • “Complete or partial dentures will not routinely be replaced when they have been provided by the Medicaid program and become unserviceable or are lost within eight years, except when they become unserviceable through extensive physiological change. If the recipient can provide documentation that reasonable care has been exercised in the maintenance of the prosthetic appliance, and it did not become unserviceable or lost through negligence, a replacement may be considered. Prior approval requests for such replacements will not be reviewed without supporting documentation. A verbal statement by the recipient that is then included by the provider on the prior approval request would generally not be considered sufficient.” FH #6755535N (available here

  • Example: Appellant’s dentist requested prior authorization for denture replacement prior to the 8 year waiting period. Appellant testified that she lost her lower denture at home. Her looks and speech were unaffected but the lack of lower dentures were detrimental to her health because she was unable to eat the healthy diet required as an insulin-dependent diabetic. She was forced to eat by pressing food against her upper palate with her thumb. Agency denial upheld. Even though appellant could not eat the food she required for her diabetes, appellant presented no objective medical evidence to support her contention that her lack of the lower denture will cause her health to be compromised. Her testimony alone was insufficient; objective medical documentation is required. FH #6755535N.  (available here

  • Example: Appellant requested replacement of broken denture prior to the 8 year waiting period. Appellant testified he was taking the denture out at night to clean when he accidentally dropped it on the floor and two of the teeth broke off. The Appellant stated that with the denture being broken, he is left without any teeth, natural or otherwise, in his mouth. He further stated that without the lower denture, he cannot use the upper one because he will just be hurting his lower gum. Agency denial upheld. Though the Appellant accidentally broke the lower denture, dentures which are broken will not be replaced unless they become unserviceable through trauma, disease or extensive physiological change. FH# 7315399K (available here

  • Exception: “Under certain circumstances the Agency will approve replacement of a lost partial denture, such as for a recipient whose mouth had undergone significant changes subsequent to the incident — for example the loss of teeth.” FH 6394357J (available here

  • Root Canals

    • For beneficiaries age 21 and older, molar endodontic therapy will be considered when (1) the tooth in question is a critical abutment for an existing functional prosthesis and (2) the tooth cannot be extracted and replaced with a new prosthesis. See Dental Policy and Procedure Code Manual, page 38.

    • Denials have been overturned for:

      • Tooth is a critical abutment

        • Example: Appellant’s dentist submitted a prior authorization for root canal therapy on Appellant’s tooth number 18 (molar). Appellant confirmed that she is not missing other teeth, all of her teeth are intact and healthy, and she does not have a bridge or denture for which tooth number 18 would serve as a critical abutment. However, the Appellant asserted that she is in extreme pain, and is unable to chew her food on the right side of her mouth (the side where tooth number 18 is located). The Appellant  failed to establish that tooth number 18 is necessary to support a bridge or denture. Nor was she able to establish that extraction of tooth number 18 is contraindicated for health reasons. Because the tooth was not necessary to support any prosthetics, the Plan’s determination to deny the requested root canal for tooth number 18 was upheld. FH# 7360626Q  (available here

      • Extraction is medically contraindicated

        • Example: Fidelis (by DentaQuest) determined to deny the Appellant’s dentist’s prior approval request for a root canal on teeth numbers 2 and 18 on the ground that the service is not covered for members age 21 or older and that the service could be covered if pulling the tooth cannot be done because of a medical illness or if the tooth is needed for a bridge or a partial denture the Appellant already has. The plan further determined to deny the Appellant’s dentist’s prior approval request for a crown (D2751) on the same teeth on the ground that the root canal treatment was not approved. The record establishes that the Appellant’s oral surgeon had advised by a letter dated March 11, 2015 that the Appellant not have any extractions, because, due to her “clenching and TMJ Disorder, any surgical extractions will worsen patient condition.” Denial was reversed. FH# 7062037L  (available here

      • Medical necessity

        • Example: On December 28, 2016 the Appellant’s dentist requested prior authorization for a root canal on tooth number 15 (code D3330). On December 28, 2016 the Agency determined to deny the request on the grounds that the service is not covered by the Agency. The Agency did not review the Appellant’s request based on whether the dentist’s request for a root canal falls under the medically necessary guidelines. 18 NYCRR 513.0, provides that prior approval of medical, dental and remedial care, services or supplies is required under the MA program, such prior approval will be granted when the medical, dental and remedial care, services or supplies are shown to be medically necessary to prevent, diagnose, correct or cure a condition of the recipient. The denial was reversed. FH # 7484720Z  (available here

MANY DENTAL CLINICS ARE COVERED UNDER MEDICAID

  • In addition to a plan’s network of dental providers, plan members have the right to access dental services at the five New York Academic Dental Center clinics licensed under Article 28 of the NY Public Health Law.

  • Dental clinics are reimbursed on a rate basis or through Ambulatory Patient Groups (APGs) such as hospital outpatient departments, diagnostic and treatment centers, and dental schools, are required to follow the policies stated in the Dental Provider Manual. See Dental Policy and Procedure Code Manual, page 8.

  • Dental services at these clinics may be accessed without prior approval and without regard to network participation.

  • The plan must reimburse the clinic for covered dental services provided to enrollees at approved Medicaid clinic rates.

  • New York State Dental Centers:






Go to Source

Medicaid Dental Benefit in NYS