Accident at home...fell and had sevier facal injuries including the
loss of three teeth. Medicare of Az. states that  Dental is not
covered. But the dentist had to reconstruct the upper bone where the
teeth were. Medicare covered the ER room expences, xrays, scannings
etc.. why not the reconstruction ???

Hello-

First, let me say that I am very sorry to hear of your fall, and I
extend my condolences to you for your situation.  I want to also say
that this question is not finished until you're fully satisfied with
it, so feel free to ask for any necessary clarifications or additional
information you may need.

There is hope for a possible turn-around of your situation through an
appeals process.  Coverage is based on medical necessity, which is a
function of the dentist's/doctor's word and the condition itself.  The
medical necessity of it *must* be stressed to Medicare in order for
coverage to be an option in this case, because ordinarily, Medicare
does not cover dental work as outlined in their federally set policy.

Here is the official policy, right from the Medicare manual at the
Centers for Medicare & Medicaid Services (formerly the Health Care
Financing Administration):

Publication 14, part 3, claims process, cptr. 2, part 2136
http://www.cms.gov/manuals/14_car/3b2125.asp#_1_5


07-94    COVERAGE AND LIMITATIONS    2136

2136.    DENTAL SERVICES

As indicated under the general exclusions from coverage, items, and
services in connection with the care, treatment, filling, removal, or
replacement of teeth or structures directly supporting the teeth are
not covered. Structures directly supporting the teeth means the
periodontium, which includes the gingivae, dentogingival junction,
periodontal membrane, cementum of the teeth, and alveolar process.

In addition to the following, see §2020.3 and Coverage Issues Manual,
§50-26 for specific services which may be covered when furnished by a
dentist. 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.

EXAMPLE 1: The reconstruction of a ridge performed primarily to
prepare the mouth for dentures is a noncovered procedure. However,
when the reconstruction of a ridge is performed as a result of and at
the same time as the surgical removal of a tumor (for other than
dental purposes), the totality of surgical procedures is a covered
service.

EXAMPLE 2: Make payment for the wiring of teeth when this is done in
connection with the reduction of a jaw fracture.

The extraction of teeth to prepare the jaw for radiation treatment of
neoplastic disease is also covered. This is an exception to the
requirement that to be covered, a noncovered procedure or service
performed by a dentist must be an incident to and an integral part of
a covered procedure or service performed by him/her. Ordinarily, the
dentist extracts the patient's teeth, but another physician, e.g., a
radiologist, administers the radiation treatments.

When an excluded service is the primary procedure involved, it is not
covered, regardless of its complexity or difficulty. For example, the
extraction of an impacted tooth is not covered. Similarly, an
alveoplasty (the surgical improvement of the shape and condition of
the alveolar process) and a frenectomy are excluded from coverage when
either of these procedures is performed in connection with an excluded
service, e.g., the preparation of the mouth for dentures. In a like
manner, the removal of a torus palatinus (a bony protuberance of the
hard palate) may be a covered service. However, with rare exception,
this surgery is performed in connection with an excluded service,
i.e., the preparation of the mouth for dentures. Under such
circumstances, do not pay for this procedure.

Whether such services as the administration of anesthesia, diagnostic
X-rays, and other related procedures are covered depends upon whether
the primary procedure being performed by the dentist is itself
covered. Thus, an X-ray taken in connection with the reduction of a
fracture of the jaw or facial bone is covered. However, a single X-ray
or X-ray survey taken in connection with the care or treatment of
teeth or the periodontium is not covered.

Make payment for a covered dental procedure no matter where the
service is performed. The hospitalization or nonhospitalization of a
patient has no direct bearing on the coverage or exclusion of a given
dental procedure.

Payment may also be made for services and supplies furnished incident
to covered dental services. For example, the services of a dental
technician or nurse who is under the direct supervision of the dentist
or physician are covered if the services are included in the dentist's
or physician's bill.

Rev. 1495/Page 2-86.1 

---

In a nutshell, the above is why you were denied coverage, if
sufficient medical necessity was not an integral part of the original
claim.

What you need to do is contact Noridian Mutual Insurance, the carrier
for Medicare Part B -- doctor/dentist/"provider"-oriented coverage --
in Arizona.  They can be reached at 1-800-444-4606 [option 2].  Talk
to pretty much any representative there, and they can talk to you
about your original claim and what you need to do to set up an appeal.
 You will definitely need to get a written notice from your dentist
which will detail the severity of your situation and the medical
necessity it imposes.  Your original claim will then be re-examined. 
If it is denied again, you can have a hearing, where I would consult
with a local lawyer.  You can find lawyers who specialize in
Medicare-oriented work at this website:

Attorney Locate
http://www.attorneylocate.com/city.asp?city_statecode=AZ


Hope this helps!  Again, please let me know if you need any
clarification.


Search strategy:
   Constultation with
   Kate Driggers
   http://www.katedriggers.com/arizona.htm

   CMS website
   www.cms.gov
   
   1-800-MEDICARE
   
   
Thank you,

jbf777-ga
GA Researcher

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Request for Answer Clarification by billyb-ga on 26 Jun 2003 11:37 PDT

Your answer does help...I did not state that I have AARP Medicare
Supplemental Insurance coverage....BUT they will not look at the
claim: the claim MUST be pass through the Medicare system, then on to
the supplement plan...called medicare and they will not accept ANY
claim that is dental..so says the girl on the phone....my dentist will
not mail any information to my medicare office, for the Dentist states
that they do not accept Medicare patients!!! Have been with the
dentist for 10 years...I want to force him to enter the claim, for
medicare will not take or accept any form of a claim from me...I feel
like Catct 22...THank you for the first info....BIllyb-ga

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Clarification of Answer by jbf777-ga on 26 Jun 2003 12:04 PDT

Hello Billyb-

Medicare DOES do dental work in certain circumstances, particularly in
claims with medical necessity, such as your situation -- which is very
atypical.

Medicare also does personal reimbursements in certain circumstances,
if the claim can be covered.  That means you can pay the bill to your
dentist, and Medicare could reimburse you for the charges.

At this point, your dentist is out of the loop if he doesn't take
Medicare, which means your only real option is to pursue reimbursement
from Medicare directly.

What you need to do is get a certified letter from your dentist
concerning the medical necessity of your operation, and submit that
along with your appeal to Medicare.  An appeals officer should contact
you about your claim.  Hopefully your situation can be rectified in
this manner.

Let me know if you have any other questions.

jbf777-ga
GA Reseracher

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Clarification of Answer by jbf777-ga on 26 Jun 2003 12:07 PDT

You might need some legal support behind this situation -- someone who
is versed in laws governing medicare coverage.  I would definitely
consult with a lawyer, particularly if you come up against some
roadblocks.