The Administrative Law Judge issued a decision on January 26, 2001. The appellant has asked the Medicare Appeals Council to review this decision.

The Medicare Appeals Council grants the request for review pursuant to 20 CFR 404.967 and 404.970 because there is an error of law. The appellant's request for review of the Administrative Law Judge's decision has been entered into the record as Exhibit MAC-1. Because the appellant did not send a copy of its request for review to the beneficiary, the Council forwarded a copy to the beneficiary with a cover letter dated April 27, 2001, which has been entered into the record as Exhibit MAC-2, and gave the beneficiary an opportunity for comment. The Council has not received any response to its letter. We hereby reverse the Administrative Law Judge's decision for the following reasons.

The appellant requested pre-service approval for dental implants from his Medicare Plus Choice plan. The plan stated that the services were not covered (Exhibit 3). The appellant requested a reconsideration and the Center for Health Dispute Resolution upheld the pre-service denial on the basis that the services were excluded from coverage under the provisions of 42 CFR 411.15 (Exhibit 4).

The Administrative Law Judge found that the appellant should provide the post cancer dental implants as recommended by several of his physicians. In support, he relied on the following: 1) that the beneficiary would not need the implants were it not for his underlying condition and 2) that previous dental work related to the beneficiary's cancer treatment had been covered by Medicare. With respect to the second factor, the Administrative Law Judge added that the dental implants would be, in essence, another in a series of staged procedures necessitated by the beneficiary's underlying carcinoma. The Administrative Law Judge then found that the post cancer dental implants at issue were reasonable and necessary and that they were covered under the Medicare Act.

Section 1862(a)(12) of the Social Security Act provides that:

"Notwithstanding any other provision of this subchapter, no payment may be made under part A or part B of this subchapter 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, except that payment may be made under part A of this subchapter in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services"

Further, 42 CFR 411.15, provides that

(i) Dental services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth, except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of-

(1) The individual's underlying medical condition and clinical status; or

(2) The severity of the dental procedures.

Section 2020.3 of the Medicare Carrier's Manual (MCM) states that

"payment for the services of dentists is also limited to those procedures which are not primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth."

Further, section 2136 of the Medicare Carrier's Manual provides that

"If an otherwise noncovered procedure or service is performed by a dentist as incident to and as an integral part of a covered procedure or service performed by him/her, the total service performed by the dentist on such an occasion is covered."

For the services in question to be covered under the exceptions provided in MCM 2020.3, they must be both incident to and an integral part of another covered procedure. In the instant case, the beneficiary underwent oral surgery and radiation therapy for squamous cell cancer in March and May 1999 respectively. (Exhibit 12.) The proposed dental implants are not an integral part of either procedure. Moreover, the implants are not one of a series of dental procedures that have been authorized and paid for by Medicare. For example, the teeth extractions referred to in the decision were performed prior to the beneficiary's entitlement to Medicare in June 2000. ⁽¹⁾

Because the dental implants are not an integral part of a covered procedure, they do not fall within the exception to non-coverage described in MCM 2020.3. Therefore, the dental implants are excluded from coverage under the provisions of section 1862(a)(12) of the Social Security Act, and the managed care organization is not required to provide them to the beneficiary.

FINDINGS OF THE MEDICARE APPEALS COUNCIL

1. The beneficiary is a member of a Medicare Plus Choice managed care plan.
2. The beneficiary has requested that the plan preauthorize dental implants.
3. Section 1862(a)(12) of the Social Security Act excludes dental implants from coverage.
4. The services requested by the beneficiary are not incidental to treatment for a covered service.
5. The services requested by the beneficiary are not integral to treatment of a covered service.
6. The dental implants requested by the beneficiary are excluded from coverage.
7. The Medicare Plus Choice plan is not required to authorize the dental implants requested by the beneficiary.

DECISION OF THE MEDICARE APPEALS COUNCIL

It is the decision of the Medicare Appeals Council that the dental implants requested by the beneficiary are excluded from coverage by section 1862(a)(12) of the Social Security Act. It is the further decision of the Medicare Appeals Council that the Medicare Plus Choice organization is not required to authorize the dental implants.

M. Susan Wiley
Adminstrative Appeals Judge

Clausen Krzywicki
Adminstrative Appeals Judge

1. In its request for review, the appellant noted that the beneficiary was not eligible for Medicare until June 2000. Computer records maintained by the Social Security Administration confirm this statement. A copy of the computer record has been entered into the record as Exhibit MAC -3.