New York’s Medicaid program includes limited dental benefits. The coverage has been expanded beginning on January 31, 2024 as the result of the settlement of the Ciaramella v. McDonald case (originally Ciaramella v. Zucker).
This article will go over general Medicaid dental rules and common issues. It will also give background on the lawsuit and provide the new coverage rules under the settlement, which applies to adults for root canals, crowns, replacement dentures and dental implants.
If you have not yet seen a dentist, please refer to this article on Legal Aid’s website about using Medicaid to access health care.
If you need advice about a specific Medicaid dental case, you can contact The Legal Aid Society's Access to Benefits helpline at (888) 663-6880.
Ciaramella v. McDonald
In August, 2018, The Legal Aid Society and co-counsel filed Ciaramella v. Zucker (18-cv-06945) to challenge the New York State Department of Health’s rules for adults that prevent Medicaid coverage for replacement dentures within 8 years from initial placement and the ban on Medicaid coverage for dental implants. In response, DOH changed the rules for replacement dentures and also changed the dental implant rules to allow for coverage in certain narrow circumstances. Those changes went into effect on November 12, 2018.
The case was amended to include a challenge to the revised rules for Medicaid coverage for dental implants, replacement dentures and to add a challenge to Medicaid coverage rules for root canal and crowns.
The parties reached an agreement that dramatically expands Medicaid dental coverage for adults for root canals, crowns, replacement dentures, and dental implants. In October 2023, the court approved the settlement agreement, which includes changes to the rules in the Dental Manual and a Guidance document. DOH must maintain the new rules for 4 years. This article discusses these rules below. All citation to the “Dental Manual” refer to this document.
Please refer to this article for rules that apply to requests for services made prior to January 31, 2024.
The approved settlement can be found here.
For more information about the lawsuit, see article in New York Times, August 2, 2018, "Lack of Dental Coverage Hampers Medicaid Recipients, Suit Says" and this article about the settlement, Hoping for a Root Canal: 5 Million New Yorkers Get More Dental Coverage.
This article is not an exhaustive discussion of the new rules and the Guidance. The dental manual can be found here and a Guidance document here.
WHAT DENTAL SERVICES ARE COVERED UNDER MEDICAID?
New York’s Medicaid program includes dental services. N.Y. Soc. Serv. Law § 365-a(2).
New York regulations limit Medicaid coverage for dental care to “preventive, prophylactic and other routine dental care, services and supplies, and dental prosthetic and orthodontic appliances required to alleviate a serious health condition including one which affects employability” and those that are “deemed essential to maintain an adequate level of dental health.” 18 N.Y.C.R.R. § 506.2
The detailed rules of what dental services are covered by New York’s Medicaid program appear in the New York State Medicaid Program Dental Policy and Procedure Code Manual or the “Dental Manual”.
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- Essential Services. The Manual states when reviewing requests for services the following guidelines will be used:
- Caries index, periodontal status, recipient compliance, dental history, medical history and the overall status and prognosis of the entire dentition, among other factors, will be taken into consideration when determining medical necessity.
- Treatment is considered appropriate where the prognosis of the tooth is favorable.
- Treatment may be appropriate where the total number of teeth which require or are likely to require treatment is not considered excessive or when maintenance of the tooth is considered essential or appropriate in view of the overall dental status of the recipient.
(Dental Manual, page 18)
- Excluded Services. The Manual excludes the following dental services from Medicaid coverage:
- Fixed bridgework, except for cleft palate stabilization, or when a removable prosthesis would be contraindicated;
- Immediate full or partial dentures;
- Crown lengthening, except when associated with medically necessary crown or endodontic treatment;
- Dental work for cosmetic reasons or because of the personal preference of the recipient or provider;
- Periodontal surgery, except when associated with implants or implant related services;
- Gingivectomy or gingivoplasty, except for the sole correction of severe hyperplasia or hypertrophy associated with drug therapy, hormonal disturbances, or congenital defects;
- Adult orthodontics, except in conjunction with, or as a result of, approved orthognathic surgery necessary in conjunction with an approved course of orthodontic treatment or the on-going treatment of clefts;
- Placement of sealants for members under 5 or over 15 years of age; and
- Improper use of panoramic images (D0330) along with intraoral complete series of images (D0210)
(Dental Manual, page 7)
A Guidance document gives clarification and examples related to the new rules. This is not an exhaustive discussion of the guidance. It states, in part, that:
- The aim of these revisions is to maintain a member’s natural dentition whenever clinically appropriate.
- MCOs and fee-for-service providers are required to use the criteria as set forth in the Dental Manual and may not impose additional or more restrictive criteria.
- Prior authorization requests for root canals, crowns, replacement dentures and dental implants may NOT be denied on the basis that they are not covered services. Enrollees are entitled to external appeal rights.
(Guidance, page 1)
Children’s Dental Benefit. A child is defined as anyone under the age of 21. Dental services for children are provided as part of Medicaid’s Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. Under this program, children can receive periodic oral evaluations and preventive, restorative, and emergency dental care. The provider manual clarifies that this means children should receive routine preventive dental care every six months, and additional visits should be based upon the dentist’s assessment of the child’s individual needs. (New York Medicaid Child/Teen Health Program (C/THP) Provider Manual, page 12).
Medicaid Orthodontic Benefit. The Medicaid Orthodontic Benefit is for children under 21 years old with severe physically handicapping malocclusions (a malocclusion is imperfect positioning of the teeth when the jaws are closed). The coverage is limited to three years of treatment and one year of retention care. Cleft palate or approved orthognathic surgical cases may be approved for additional treatment time. Treatment not completed within the maximum allowed period must be continued to completion without additional compensation for the NYS Medicaid program, the recipient, or the family. (Dental Manual, page 54).
WHAT IF MEDICAID DENIES THE CLAIM?
If you believe your claim has been improperly denied, you may request a plan appeal (in Medicaid managed care) or a Fair Hearing. If the plan appeal is denied, you can request an External Appeal with the New York State Department of Financial Services.
An overview of Grievances and Appeal rights is available in this article linked here.
FAIR HEARINGS and EXTERNAL APPEALS
- General suggestions for succeeding at a fair hearing:
- Establish, through evidence, that the procedure is medically necessary.
- Social Services law defines medical necessity as medical, dental, and remedial care, services and supplies which are necessary to prevent, diagnose, and correct or cure conditions in the person that may cause acute suffering, endanger life, result in illness or infirmity, interfere with such person’s capacity for normal activity or threaten some significant handicap. Social Services Law 365-a(2).
- Provide as much evidence and medical documentation as possible of the need for and benefit of the work. Credible testimony by the appellant alone is generally not sufficient in these types of cases.
- Decisions are often remanded, or sent back to the plan to make another determination, when the plan fails to provide support for their basis of denial.
- Ask the dentist to testify during the fair hearing or to provide a written statement of a denial’s impact on the client’s health.
- Provide research, studies or statements from professional organizations to support the necessity of the request.
- If a root canal, crown, dental implant or replacement denture was denied prior to January 31, 2024, it is possible that is approvable under the new rules. Talk to your provider and ask if they will resubmit the request. If the case is already at a fair hearing, the Administrative Law Judge may remand it back to the plan to review the case under the new rules.
EXPANDED SERVICES
Root Canals
Beginning January 31, 2024 the Dental Manual states:
Root canal therapy for members under the age of 21 will be covered when medically necessary. In determining whether a requested root canal is medically necessary, the following factors may be considered:
• The periodontal status, member compliance and overall status and prognosis of the tooth is favorable.
• The tooth is not routinely restorable with a filling
Root canal therapy for members 21 and over will be covered when medically necessary. In determining whether requested endodontic treatment is medically necessary, the following factors may be considered:
• There is a documented medical condition which precludes an extraction
• The tooth is a critical abutment for an existing or proposed prosthesis
• If the tooth is a posterior tooth, the following additional factors may be considered:
- The periodontal status, member compliance and overall status and prognosis of the tooth is favorable
- There are eight or more natural or prosthetic posterior points of contact present
- If the posterior tooth is a molar, treatment of the molar is necessary to maintain functional or balanced occlusion of the patient’s dentition
- Consideration for a third molar will be given if the third molar occupies the first or second molar position
- Note: Requests for treatment on unopposed molars must include a narrative documenting medical necessity
- If the tooth is an anterior tooth, the following additional factors may be considered:
- The periodontal status, member compliance and overall status and prognosis of the tooth is favorable
(Dental Manual, page 31)
Key changes include:
- The 8 points of contact rule is no longer a basis to deny coverage.
- A root canal will be covered where there are eight (8) or more points of natural or prosthetic contact unless there is a documented indication to extract the tooth. (Guidance, page 11)
- Coverage for a molar root canals should be provided where the treatment is necessary to maintain functional or balanced occlusion of the patient’s dentition (Guidance, page 11)
The Guidance document provides further clarification and examples including:
- The bullet points contained in the “Endodontics” section of the Dental Manual should all be considered when formulating a treatment plan but are NOT mutually exclusive, meaning that not all factors must be satisfied for a root canal to be covered. (Guidance, page 10)
- A root canal will be covered where there are eight (8) or more points of natural or prosthetic contact unless there is a documented indication to extract the tooth. (Guidance, page 10)
- If a patient has eight (8) or more points of contact, coverage of a root canal WILL NOT be denied under the justification that the molar is not “necessary to maintain balanced or functional occlusion of the patient’s dentition” (Guidance, page 12)
- In order for a molar to be considered unopposed, it must be entirely unopposed as determined by radiographic evidence. Example: Tooth #14 is typically in occlusion with teeth #19 and #20. However, radiographic evidence demonstrates that tooth #14 is unopposed because both tooth #19 and tooth #20 are missing. In contrast, tooth #14 is opposed if only tooth #19 or only tooth #20 is missing. (Guidance, page 12)
Below are examples of denials overturned prior to the 2024 changes:
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- Extraction is medically contraindicated
- Example: Fidelis (by DentaQuest) determined to deny the Appellant's dentist's prior approval request for a root canal on teeth numbers 2 and 18 on the ground that the service is not covered for members age 21 or older and that the service could be covered if pulling the tooth cannot be done because of a medical illness or if the tooth is needed for a bridge or a partial denture the Appellant already has. The plan further determined to deny the Appellant’s dentist’s prior approval request for a crown (D2751) on the same teeth on the ground that the root canal treatment was not approved. The record establishes that the Appellant’s oral surgeon had advised by a letter dated March 11, 2015 that the Appellant not have any extractions, because, due to her “clenching and TMJ Disorder, any surgical extractions will worsen patient condition.” Denial was reversed. FH# 7062037L (available here)
- Medical necessity
- Example: On December 28, 2016 the Appellant’s dentist requested prior authorization for a root canal on tooth number 15 (code D3330). On December 28, 2016 the Agency determined to deny the request on the grounds that the service is not covered by the Agency. The Agency did not review the Appellant’s request based on whether the dentist’s request for a root canal falls under the medically necessary guidelines. 18 NYCRR 513.0, provides that prior approval of medical, dental and remedial care, services or supplies is required under the Medicaid program, such prior approval will be granted when the medical, dental and remedial care, services or supplies are shown to be medically necessary to prevent, diagnose, correct or cure a condition of the recipient. The denial was reversed. FH # 7484720Z (available here)
Crowns
Beginning January 31, 2024 the Dental Manual states:
Crowns for members under the age of 21 will be covered when medically necessary. In determining whether a requested crown is medically necessary, the following factors may be considered:
• The periodontal status, member compliance and overall status and prognosis of the tooth is favorable.
• The tooth is not routinely restorable with a filling.
Crowns for members 21 years of age and over will be covered when medically necessary. In determining whether a crown is medical necessary, the following factors may be considered:
• There is a documented medical condition which precludes extraction.
• The tooth is a critical abutment for an existing or proposed prosthesis.
• If the tooth is a posterior tooth, the following additional factors may be considered:
- The periodontal status, member compliance and overall status and prognosis of the tooth is favorable.
- The tooth is not routinely restorable with a filling.
- There are eight (8) or more natural or prosthetic points of contact present.
- If the posterior tooth is a molar, treatment of the molar is necessary to maintain functional or balanced occlusion of the patient’s dentition.
- Consideration for a third (3rd) molar will be given if the third (3rd) molar occupies the first (1st) or second (2nd) molar position.
- Note: Requests for treatment on unopposed molars must include a narrative documenting medical necessity.
- If the tooth is an anterior tooth, the following additional factors may be considered:
- The periodontal status, member compliance and overall status and prognosis of the tooth is favorable.
- The tooth is not routinely restorable with a filling
(Dental Manual, page 29)
Key changes include:
- The 8 points of contact rule is no longer a basis to deny coverage of a crown.
- A crown will be covered where there are eight (8) or more points of natural or prosthetic contact unless there is a documented indication to extract the tooth. (Guidance, page 11)
- Coverage for a molar root canal should be provided where the treatment is necessary to maintain functional or balanced occlusion of the patient’s dentition (Guidance, page 11)
Just as with Root Canals the Guidance document provides further clarification and examples including:
- The bullet points contained in the “Crowns” section of the Dental Manual should all be considered when formulating a treatment plan but are NOT mutually exclusive, meaning that not all factors must be satisfied for a root canal to be covered. (Guidance, page 6)
- A crown will be covered where there are eight (8) or more points of natural or prosthetic contact unless there is a documented indication to extract the tooth. (Guidance, page 6)
- Coverage of a crown on a molar WILL be considered if the molar is necessary to maintain balanced or functional occlusion of the patient’s dentition. Note: If a patient has eight (8) or more points of contact, coverage of a crown WILL NOT be denied under the justification that the molar is not “necessary to maintain balanced or functional occlusion of the patient’s dentition”. (Guidance, page 8)
Crown lengthening
Beginning January 31, 2024 crown lengthening will be covered when associated with a covered crown and/or covered root canal procedure. (Dental Manual, page 7, 28, 33)
The Dental Manual reads:
- Crown lengthening requires reflection of a full thickness flap and removal of bone, altering the crown to root ratio.
- The periodontal status, member compliance, and overall status and prognosis of the tooth may be taken into consideration when determining medical necessity.
- Crown lengthening is reimbursable solely when associated with medically necessary crown or root canal procedure.
- All requests for coverage of a crown lengthening should include a complete treatment plan addressing all areas of pathology. The provider must keep in the treatment record detailed documentation describing the need for crown lengthening including pretreatment photographs depicting the condition of the tissues.
- Coverage of a crown lengthening should be requested at the same time as a request for coverage of a crown and/or a root canal.
- If the need for crown lengthening is discovered during a procedure, then providers should refer to Prior Approval Change Request information on page 14.
(Dental Manual, page 33-34)
Replacement Dentures
Beginning January 31, 2024 the Dental Manual states:
Complete dentures and partial dentures, whether unserviceable, lost, stolen, or broken will not be replaced for a minimum of eight (8) years from initial placement except when determined to be medically necessary by the Department or its agent. Prior approval requests for replacement dentures prior to eight (8) years must include a completed Justification of Need for Replacement Prosthesis form signed by the patient’s dentist, explaining the specific circumstances that necessitates replacement of the denture. If replacement dentures are requested within the eight (8) year period after they have already been replaced once, then the dentist’s supporting documentation must include an explanation of preventative measures instituted to alleviate the need for further replacements.
(Dental Manual, page 35)
Key changes include:
- It is no longer necessary to provide a letter from a physician.
- You no longer need to show that dentures would alleviate a serious health condition.
- A sample of the prior authorization form can be found here.
- The Prior Authorization Form DOES NOT need to be notarized, and MCOs and Fee-for-Service providers cannot impose additional criteria other than what is provided on NYS DOH Prior Authorization Form. (Guidance, page 14)
- The supporting documentation detailing the preventative measures implemented to prevent future loss of a member’s denture(s) is ONLY required when a subsequent request for replacement denture(s) is made within eight (8) years of the member’s prior request for denture(s). (Guidance, page 14)
Implant Services
Beginning January 31, 2024, the Dental Manual reads:
Dental implants, including single implants, and implant related services, will be covered by Medicaid when medically necessary. Prior approval requests for implants must have supporting documentation from the patient’s dentist. The patient’s dentist’s office must submit a completed Evaluation of the Dental Implant Patient Form documenting, among other things, the patient’s medical history, current medical conditions being treated, list of all medications currently being taken by the patient, explaining why implants are medically necessary and why other covered functional alternatives for prosthetic replacement will not correct the patient’s dental condition, and certifying that the patient is an appropriate candidate for implant placement. If the patient’s dentist indicates that the patient is currently being treated for a serious medical condition, the Department may request further documentation from the patient’s treating physician.
(Dental Manual, page 39)
Single implants may be covered, however, the manual also states:
The dentist’s explanation as to why other covered functional alternatives for prosthetic replacement will not correct the patient’s dental condition will be reviewed based on the presence/absence of eight (8) points of natural or prosthetic posterior occlusal contact and/or one (1) missing maxillary anterior or two (2) missing mandibular teeth.
(Dental Manual, page 39)
The Guidance states: Single tooth implants are covered if they meet the other coverage criteria set forth in Section VIII of the Dental Manual. (Guidance, page 16)
Key changes include:
- It is no longer necessary to provide a letter from a physician.
- You no longer need to show that implants would alleviate a medical condition.
- A sample of the prior authorization form can be found here.
Guidance document provides further clarification and examples including:
- The Prior Authorization Form DOES NOT need to be notarized, and MCOs and Fee-for-Service providers cannot impose additional criteria other than what is provided on NYS DOH Prior Authorization Form
- A member’s dentist must still explain, with supporting medical documentation, why a dental implant is medically necessary.
- Example: Medical necessity may include, but is not limited to, partial or complete edentulism or traumatic injury to osseous structures of head, jaw and/or face resulting in inadequate remaining osseous support for conventional dental prosthesis.
- Medical necessity will be evaluated on a case-by-case basis. A member’s dentist must also still explain why other functional alternatives for prosthetic replacement (such as a partial denture) would not correct the member’s dental condition.
- Examples: (1) a member may be unable to operate a removeable prosthesis due to a neurological disorder (i.e., a seizure disorder, Parkinson’s disease); (2) a member may lack the bone support necessary to maintain a removable prosthesis.
(Guidance, page 16)
OTHER COMMON ISSUES
Initial Placement of Dentures
Initial placement of dentures was not a part of the settlement. The rules have not changed. The Dental Manual states:
- Full and/or partial dentures are covered by Medicaid when they are determined to be medically necessary, including when necessary to alleviate a serious condition or one that is determined to affect employability. This service requires prior approval.
- Requests for partial dentures will be reviewed based on the presence/absence of eight (8) points of natural or prosthetic posterior occlusal contact and/or one (1) missing maxillary anterior or two (2) missing mandibular teeth.
(Dental Manual, page 35)
This means that if a person has four maxillary (upper jawbone) and four mandibular (lower jawbone) teeth in functional contact with each other, they are likely to be denied initial placement of dentures.
In requesting the service, or appealing a denial provide as much documentation as possible to show that the procedure was medically necessary and that an insufficient number of teeth in occlusion met the points of contact rule or that that not having dentures affects employability.
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- Example: Appellant was approved for placement of an upper denture but was denied for a lower partial denture. The Agency denial was upheld because the placement of the upper denture satisfied the 8 points of contact rule between the upper and lower back teeth. At the fair hearing the appellant’s testimony of how she was unable to chew properly because of the constant pain and how that pain interfered with her capacity to perform the duties of her job was found to be credible. However, the appellant failed to establish that other treatments, even if less cosmetically ideal, would not eliminate the pain. Furthermore, the record failed to establish that the upper denture had yet been placed. Placement of the upper denture was expected to improve appellant’s chewing ability. Plan decision was upheld. FH# 7261543K (available here)
- Example: Agency denied appellant’s request for a lower partial denture because the appellant had 8 points of contact without the denture. The appellant did not dispute that she had the 8 points of contact. However, the appellant stated that she suffered from Multiple Sclerosis, which paralyzed the right side of her mouth. Consequently, she could only use the left side of her mouth to eat. The agency’s denial was affirmed because although the appellant’s testimony indicated that she might have qualified for the partial lower denture, the appellant failed to present any medical documentation that proved her medical condition. FH# 6655671H (available here)
Interrupted Treatment Policy.
When an individual changes insurers (either fee-for-service to Medicaid managed care (MMC) or changes plans) in the midst of a course of treatment, the insurer at the time of the decisive appointment is responsible for the payment for the entire treatment. Claims must be submitted when the product or service is completed and delivered to the recipient with the appropriate procedure code using the date that the service was actually completed and delivered as the date of service. See Dental Manual, page 20 for a chart of the “decisive appointments” for various services.
RELEVANT RULES AND REGULATIONS
- 18 NYCRR 506.2: Dental Care:
- "Dental care in the medical assistance program shall include only preventive, prophylactic and other routine dental care, services and supplies, and dental prosthetic and orthodontic appliances required to alleviate a serious health condition including one which affects employability.”
- For more information about what services are included, see the state regulation.
- 18 NYCRR 506.3: Authorization for dental services and supplies:
- The identification card issued to persons eligible for medical assistance shall constitute full authorization for providing a select list of dental services and supplies and no special or prior authorization shall be required for these services.
- For information on which services do and do not require prior approval and authorization, click on this link to the regulation:
- 18 NYCRR 506.4: Orthodontic Care:
- NYS Dental Policy and Code Manual:
- The rules and limitations for different dental services are included in the policy manual. Managed care plans, providers, and ALJs rely on the manual in determinations about dental coverage.
MANY DENTAL CLINICS ARE COVERED UNDER MEDICAID
- In addition to a plan’s network of dental providers, plan members have the right to access dental services at the five New York Academic Dental Center clinics licensed under Article 28 of the NY Public Health Law.
- Dental clinics are reimbursed on a rate basis or through Ambulatory Patient Groups (APGs) such as hospital outpatient departments, diagnostic and treatment centers, and dental schools, are required to follow the policies stated in the Dental Provider Manual. See Dental Policy and Procedure Code Manual, page 8.
- Dental services at these clinics may be accessed without prior approval and without regard to network participation.
- The plan must reimburse the clinic for covered dental services provided to enrollees at approved Medicaid clinic rates.
- New York State Dental Centers:
