When Medicare was enacted in 1965, more than half of Americans over 65 had no health insurance. The fact that Medicare provided affordable, basic health insurance was a huge boon for older Americans and their families (and, eventually, people with disabilities, who were added to the program in 1972). But, despite the tremendous successes of the program over the past 50 years, Medicare can do more to safeguard older people and those with disabilities. 

While major strides have been made in providing coverage for medications and preventive services, Medicare still lacks coverage in three important areas – eye care, hearing aids, and dental care – no matter how extreme the need. These are all key to health and well-being. 

Oral health and dental care are particularly important for older people and people with disabilities, who are often more vulnerable to infection, malnutrition, and serious illness. Unfortunately, efforts to clarify and expand Medicare’s coverage of dental services have been stymied. At best, non-routine dental services are only sometimes covered – when they are coupled with exacerbating medical conditions and generally only after lengthy appeals. Medicare contractors regularly deny coverage for nearly any care that has to do with the jaw or mouth. 

This was not the intent of the law. The Center for Medicare Advocacy frequently hears from beneficiaries with urgent health issues who cannot obtain even extraordinarily complex dental and oral health services due to inappropriately broad Medicare denials. For example, one beneficiary wrote:

I'm in desperate need of dental treatment ... for Sjogrens Disease ... I can't get needed implants for my mouth. I ended up having to get all my teeth pulled and get dentures that have failed miserably. I haven't been able to eat a solid meal for months.

The Medicare statute currently excludes coverage of dental services as follows:

No payment may be made [by Medicare] . . . for any expenses incurred for items or services – . . . where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth . . . 42 U.S.C. § 1395y(12).

Congress deliberately placed the dental services exclusion in a section of the Medicare statute that also excludes coverage for a number of other medical services that are generally considered to be “routine.” This means that the exclusion was not intended to apply to reasonable and necessary medical treatment that could affect patient survival. 

Medicare coverage of “extreme dental care” is of particular concern to cancer patients who require special care necessitated by the effects of radiation and chemotherapy treatments prescribed to treat oral, head, and neck cancer. Not being able to access needed dental care can affect these patients’ overall health, increase their risk of infection, and lessen their likelihood of recovery. In fact, the inclusion of dental services is the standard of care for the treatment of oral cancer, according to the National Cancer Institute of the National Institutes of Health who write that “[i]t is essential that a multidisciplinary approach be used for oral management of the cancer patient before, during, and after cancer treatment.”

At the very least, extreme dental services can and should be covered under Medicare. To truly honor Medicare’s 50th Anniversary, coverage should be provided for these services which are so critical to the health and well-being of Medicare beneficiaries. 

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Stein, JD founded the Center for Medicare Advocacy, Inc. in 1986, where she is currently the executive director.