Page 149 - Medicare Benefit Policy Manual

limited to the administration of anesthesia, diagnostic x-rays, use of operating room, and other
related, otherwise covered procedures.

No payment is made for dental services that may be inextricably linked to, and substantially
related and integral to the clinical success of other non-covered services. Such services remain
subject to the statutory exclusion at § 1862(a)(12) for items and services in connection with the
care, treatment, filling, removal, or replacement of teeth or structures directly supporting the
teeth. More specifically, dental services inextricably linked to a non-covered medical service(s)
are not covered or payable. For example, an alveoplasty (the surgical improvement of the shape
and condition of the alveolar process) and 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. Similarly, with rare exception, the removal of a torus palatinus (a bony
protuberance of the hard palate) is performed in connection with an excluded service, i.e., the
preparation of the mouth for dentures. Under such circumstances, Medicare does not pay for this
procedure.

MACs have the flexibility to determine on a claim-by-claim basis whether a patient’s
circumstances do or do not fit within the terms of the statutory preclusion or exceptions specified
in section 1862(a)(12) of the Act and our regulation at 42 CFR § 411.15(i). These policies do
not prevent a MAC from making a determination that payment can be made for dental services in
other circumstances under which the dental services are inextricably linked to, and substantially
related and integral to the clinical success of, certain covered medical services, but are not
specifically addressed in final rules, manual provisions, and the finalized amendments to§
411.15(i).

150.1 - Treatment of Temporomandibular Joint (TMJ) Syndrome
(Rev. 1, 10-01-03)
PASS memo Read.014

There are a wide variety of conditions that can be characterized as TMJ, and an equally
wide variety of methods for treating these conditions. Many of the procedures fall within
the Medicare program’s statutory exclusion that prohibits payment for items and services
that have not been demonstrated to be reasonable and necessary for the diagnosis and
treatment of illness or injury (§1862(a)(1) of the Act). Other services and appliances
used to treat TMJ fall within the Medicare program’s statutory exclusion at 1862(a)(12),
which prohibits payment “for services in connection with the care, treatment, filling,
removal, or replacement of teeth or structures directly supporting teeth....” For these
reasons, a diagnosis of TMJ on a claim is insufficient. The actual condition or symptom
must be determined.

160 - Clinical Psychologist Services
(Rev. 51, Issued: 06-23-06, Effective: 01-01-05, Implementation: 09-21-06)

A. Clinical Psychologist (CP) Defined