Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), has conducted post-payment review of claims for dental bone grafting claims billed with dates of service (DOS) January 1, 2020, through December 31, 2021. Below are the review results:

Background

Dental services are generally excluded from Medicare coverage by statute and regulation when related to the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. When an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty. Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed. For dental services to be covered, they must be performed as incident to and as an integral part of a procedure or service covered by Medicare.

Reason for Review

The SMRC was tasked with performing medical record reviews on a sample of dental bone grafting claims billed with DOS January 1, 2020, through December 31, 2021. The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Service provided is not a covered Medicare benefit.
  • Social Security Act (SSA) 1862; 42 Code of Federal Regulations (CFR) § 411.15(i) & (k); Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM) Chapter 16; 42 CFR, Chapter 4(b) (411). According to Medicare dental coverage, dental services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth. Dental bone grafting is only covered if it is performed incident to and an integral part of a covered primary service that is necessary to treat a non-dental condition. The medical record documentation did not support that bone grafting was performed incident to a covered primary service.
• No response to the documentation request.
  • Social Security Act (SSA) 1833(e), SSA 1862(a)(1)(A), 42 Code of Federal Regulations (CFR) 424.5(a)(6). Internet-Only Manuals (IOM), Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.2.3.8 states “During post-payment review, if no response is received within the expected timeframes (or extension), the MACs, RACs, UPICs and SMRC shall deny the claim as not reasonable and necessary.”  Providers are required to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely therefore the claim was denied.

References

Social Security Act (SSA), Title XVIII

• § 1815(a) Payment to Providers of Services
• § 1833(e) Payment of Benefits
• § 1842(p)(4) Provisions Relating to the Administration of Part B
• § 1861 Part E – Miscellaneous Provisions
• § 1862(a)(1)(a) & (12) Exclusion from Coverage and Medicare as a Secondary Payer
• § 1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• § 1893(f) (7) (A) (B) (i-iv) Medicare Integrity Program

Title 42 Code of Federal Regulations (CFR)

• § 411.15 (i) & (k)(1) Particular services excluded from coverage
• § 424.5(a)(6) Basic Conditions
• § 440.100 Dental Services

Internet Only Manual (IOM), Medicare General Information, Eligibility and Entitlement Manual, Publication 100-01

• Chapter (Ch.) 5, § 70.2 Dentists

IOM, Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02

• Ch. 15, § 150 Dental Services
• Ch. 16, § 140 Dental Service Exclusion.

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 30 § 50 Advance Beneficiary Notice of Non-coverage (ABN)

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3 § 3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
• Ch. 3 § 3.3.2.4 Signature Requirements
• Ch. 3 § 3.6.2.1 Coverage Determinations
• Ch. 3 § 3.6.2.2 Reasonable and Necessary Criteria

Last Updated Dec 28, 2023