CMS Final Rule Includes Important Oral Health Clarification

Last week the Centers for Medicare & Medicaid Services (CMS) issued a final rule that announced finalized policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues. The rule included clarification to reimbursement for dental services necessary to the clinical success of certain cancer treatments. This builds on the clarification in the 2023 PFS that recognized Medicare payment for dental services that are essential to certain covered medical services. An additional important note is that the 2023 PFS also established an annual process for stakeholders to nominate additional clinical scenarios for Medicare payment of oral health care. This nominations process will take place again early next year. The Center will have a webinar in early 2024 to discuss oral health and will include a discussion of the nominations process. The final rule includes:

1. Codification of the previously finalized payment policy for dental services for head and neck cancer treatments, whether primary or metastatic. 
2. Codification to permit Medicare Part A and Part B payment for dental or oral examination performed as part of a comprehensive workup prior to medically necessary diagnostic and treatment services, to eliminate an oral or dental infection prior to, or contemporaneously with, those treatment services, and to address dental or oral complications after radiation, chemotherapy, and/or surgery when used in the treatment of head and neck cancer. 
3. Payment for certain dental services inextricably linked to other covered services used to treat cancer prior to, or during:
   1. Chemotherapy services. 
   2. Chimeric Antigen Receptor T- (CAR-T) Cell therapy.
   3. The use of high-dose bone modifying agents (antiresorptive therapy). 

• Center for Medicare Advocacy comments on proposed rule: https://medicareadvocacy.org/center-for-medicare-advocacy-submits-comments-on-proposed-physician-fee-schedule-rule/
• Statement from The Consortium for Medically Necessary Oral Health Coverage: https://medicareadvocacy.org/wp-content/uploads/2023/11/Statement-by-the-Consortium-for-Medically-Necessary-Oral-Health-Coverage_110723.pdf
• CMS Fact Sheet on Final Rule: Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule | CMS

November 9, 2023 – K. Kertesz