The 2024 Medicare Physician Fee Schedule (PFS) proposed rule released last week includes a proposal to clarify reimbursement for dental services necessary to the clinical success of certain cancer treatments. In last year’s PFS final rule, CMS clarified and codified its interpretation of the Medicare statute to recognize payment for dental services that are “inextricably linked” to certain covered medical services. It specifically provided that starting in 2023 payment could be made for examinations and treatment to identify and eradicate oral and dental infections that could complicate the outcome of organ transplant, cardiac valve replacement, and valvuloplasty procedures, and also head and neck cancer treatments (beginning in 2024). The Center had submitted comments strongly supporting that interpretation. We stated in our comments that the CMS proposal “paves the way toward ameliorating disparities in access to critical health services and bringing Medicare’s dental coverage policy up to date with clinical standards of care.”
This year’s proposal would permit Medicare payment for certain dental services required prior to or contemporaneous with some Medicare-covered cancer treatments. The relevant language from the proposed rule is excerpted below. The Center will provide additional information in the weeks ahead. Comments are due to the CMS by Sept. 11, 2023.
From the 2024 PFS proposed rule:
“[W]e propose to amend our regulation at § 411.15(i)(3)(i)(A) to permit payment
under Medicare Parts A and Part B for:
(1) Dental or oral examination performed as part of a comprehensive workup in either the inpatient or outpatient setting prior to Medicare-covered: chemotherapy when used in the treatment of cancer, chimeric antigen receptor (CAR) T-cell therapy when used in the treatment of cancer, and the administration of high-dose bone-modifying agents (antiresorptive therapy) when used in the treatment of [cancer]; and
(2) Medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to, or contemporaneously with: chemotherapy when used in the treatment of cancer, CAR T-cell therapy when used in the treatment of cancer , and the administration of high-dose bone-modifying agents (antiresorptive therapy) when used in the treatment of cancer. Furthermore, we propose that payment under the applicable payment system could also be made for services that are ancillary to these dental services, such as x-rays, administration of anesthesia, and use of the operating room as currently described in our regulation at § 411.15(i)(3)(ii).
July 20, 2023 – K. Kertesz