A federal appeals court refused to put the financial bite on Medicare for dental coverage Friday, even when the patients have serious problems such as oral cancer or the rare Sjogren’s syndrome.
The 9th U.S. Circuit Court of Appeals upheld denial of claims for Medicare coverage for dental services, finding the Secretary of Health’s interpretation of the law reasonable and that the denial did not violate equal protection or Fifth Amendment rights.
Delores Berg and Thomas DiCecco sued unsuccessfully to challenge denial of coverage.
Berg suffers from Sjogren’s syndrome, which renders her unable to produce saliva, meaning she has lost teeth, her bite collapsed, she was prone to gum infections and potential life-threatening heart infection. Her dentist performed extensive work to reconstruct her bite and correct her problems in 2008, for a cost of nearly $29,000.
Berg’s claim for Medicare Advantage provider coverage was denied.
DiCecco received a bone marrow transplant to treat chronic leukemia. The results of his treatment in 1999 cost a disease that resulted in loss of saliva function and he too lost teeth and forced him to use a feeding tube for nearly a year.
His dentist performed restorative dental work for fillings and crowns, but his dental coverage was also denied.
The circuit panel cited the broad exclusion of dental services under Medicare coverage.
“The claims of [Berg and DiCecco] are sympathetic, and their desire for coverage is understandable,” Judge Ronald Gould. “But not all medically necessary services are covered by medicare, and the Secretary has implemented a coverage framework consistent with the goals of Congress that there be broad denial of coverage for dental services.”
The Medicare Act was intended to “make clear that the services of dental surgeons covered under the bill are restricted to complex surgical procedures,” and not for “routine dental treatment” such as replacing teeth or structures.
Berg and DiCecco argued the law was not clear and the Secretary’s interpretation was flawed.
“We can see that there are fair arguments on both sides of the issue and conclude that the statute is ambiguous,” wrote Gould. But ultimately, the panel fund the Secretary’s interpretation was reasonable.
Gould also rejected the argument that the denial creates classes of coverage in violation of the Constitution’s equal protection clause.
Judges Alfred Goodwin and Kim Wardlaw joined Gould.
Case: Fournier v. Sebelius, No. 12-15478