Two adult dental Medicaid recipients of New York State, Frank Ciaramello and Richard Palazzolo, filed a class action legal complaint in US District Court for the Southern District of New York on August 2, 2018.
Their filing alleges that New York Department of Health commissioner Dr. Howard Zucker denied “New York Medicaid-eligible individuals (dental treatment) whose expenses associated with medically necessary dental services are not reimbursable by New York’s Medicaid program (‘New York Medicaid’ or the ‘Program’), because of the Program’s categorical ban on dental implants and strict limits on replacement dentures.”
The plaintiffs referenced the New York State Medicaid Program Dental Policy and Procedure Code Manual in their pleading. The manual specifically excludes treatment with dental implants in adult Medicaid coverage. It further sets an eight-year minimum time for replacement of removable oral prosthetics (complete and partial dentures). The plaintiffs argue that “medical necessity” as phrased under statutes supersedes these exclusionary policies.
Ciaramello reported inadequate bone levels to support a complete lower denture without dental implants. He stated his upper denture was loose, fell out onto the street, and was run over by a vehicle. His cited health problems include hypertension, coronary artery disease, diabetes, and protein malnourishment. Without well-fitting oral prosthetics, he has difficulty masticating food for proper nutrition, which exacerbates his diseases.
Palazzolo presented a medical history of bipolar disorder, depression, anxiety, and diabetes. He reported his denture was stolen and required replacement prior to the eight-year exclusionary time frame. Palazzolo has deep concerns about his compromised appearance, which he alleges worsens his clinical depression.
The plaintiffs are represented by the Legal Aid Society and the private law firm of Willkie Farr & Gallagher.
“We hope this case will put an end to New York’s arbitrary restrictions on dental implants and replacement dentures and make sure the state follows federal Medicaid laws,” said Wesley Powell, partner at Willkie Farr & Gallagher.
“The law makes clear that these services must be provided if they are medically necessary, and the medical consensus is that these services are medically necessary for some patients, including Mr. Ciaramella and Mr. Palazzolo. Of course, inadequate health and dental coverage and categorical treatment bans don’t just affect those on Medicaid. Those with private insurance suffer, too,” said Powell.
“It’s important to note that for the Medicaid-eligible population, if they don’t receive this coverage, they have no other prospects of getting implants or replacement dentures. They simply lack the financial resources to pay out-of-pocket,” Powell said.
“The New York State Dental Association believes that any arbitrary guideline that determines when any insurance program allows for a dental benefit to be paid is wrong,” said Mark J. Feldman, DMD, executive director of the New York Dental Association.
“The decision on proper care for a dental patient should be based on a determination of the dentist based on what is best for their patient,” Feldman continued. “We support the concept of a class action lawsuit, but feel that only focusing on limited, specific treatments does not go far enough to eliminate third party interference in the dentist-patient relationship.”
The New York State Health Department’s communications director was successfully contacted for comment. No response has been forthcoming to date.
In October 2018, a settlement was announced specific only to Ciaramella. The agreement announced that if the Medicaid insurer rejects payment for Ciaramella’s prosthetic and implants treatment, which is highly likely, the New York Department of Health would pay directly for services.
The lawsuit continues despite the settlement with Ciaramella, and Palazzolo has since been given authorization for fabrication of new dentures. The issue centers on “medical necessity” for NY Medicaid-eligible patients, as defined and in compliance with federal law.
Most recently, six new litigants were added to the class action. Two of the adult plaintiffs were denied endodontic therapy in favor of the covered service of tooth extraction. Others had issues over denial of dental implants and need of replacement dentures prior to the eight-year limitation. New York has since revised policy regulations effective November 12, 2018.
Attorneys for the class action have argued that the new policy changes are not permanent and could be altered or eliminated in the future by administrative action. Litigants are seeking stability in policy changes though an enforceable court order or by raising the public’s awareness to generate stable legislative changes.
A vital central term in this case, “medical necessity,” may have different nuanced interpretations in different states. However, under the Medicaid program, which is jointly funded by the states and federal government, “States are permitted (but not required) to set parameters that apply to the determination of medical necessity in individual cases, but those parameters may not contradict or be more restrictive than the federal statutory requirement.” (The National Academy for State Health Policy offers an overview for “medical necessity” for each of the 50 states.)
Discussion
The fiscal obligations of compliance with medical necessity for adult dental Medicaid should not be underestimated. This potentially includes costly care for fixed and removable prosthodontics, endodontic care, implant services, and surgical bone grafting. Restricted times of replacement treatments don’t apply.
Many of these patients’ cases are also complicated by very involved and compromised medical histories, both with physical and mental health. This patient care often represents highly advanced and technically involved restorative treatment, with multiple applications of specialist services.
One wonders if state Medicaid administrators can continue the pathetic game of establishing a schedule of fees so low that few if any providers will accept participation. This becomes especially problematic for highly advanced cases, usually involving dental specialists. The fees are often set so low as to effectively deny patients medically necessary care.
Numbers of states have elected to expand dental Medicaid coverage formerly limited to children to also cover disadvantaged adults. States can’t simply cherry-pick a few low-cost dental services for these adults. States are required to meet federal obligations of medical necessity for these patients.
Another factor too often unaddressed is the position of taxpayers. Taxpayers fund the Medicaid program. Yet if they are fortunate enough to enjoy dental coverage through an employer, most have an annual limitation of benefits, often $1,000 to $1,500.
Taxpayers may face serious restrictions in services, which exclude or limit dental implants, surgical bone grafting, and oral prosthetic services. But they all must address the realities of time restrictions for replacement of dental restorations and prosthetics. Other taxpayers purchase dental services out-of-pocket or simply do without.
The reality of meeting medical necessity for the adult dental Medicaid population is clearly an expensive unfunded government mandate. This will certainly be exacerbated by numbers of states agreeing to Medicaid expansion for low-income populations.
Neither states nor the federal government can truly fund such an adult dental Medicaid program without significant restructuring of government spending allocations. In fact, the current dental Medicaid program as it is operating today is funded via unsustainable government deficit spending.
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at mwdavisdds@comcast.net or smilesofsantafe.com.
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