In re Doe

No. 000-40-0610 (SSA Office of Hearings & App. Jan. 30, 1992). ; Clearinghouse Number: 51572

Description

Charges for Endodontic and Presurgical Endodontic Treatment Found Reasonable

Abstract

The administrative law judge (ALJ) has held that charges for endodontic care submitted by beneficiary’s physicians were "reasonable charges" as defined by 42 C.F.R. § 405.509 and did not exceed the inflation-index charge defined in 20 C.F.R. § 405.509; these charges should be covered by Medicare. The ALJ also held that charges for presurgical endodontic treatment did not fall within the dental service exclusion of § 1862(a)(12) of the Social Security Act and should be reimbursed in full by Medicare. Beneficiary suffered severe injuries to her face, mouth, and jaw in a car accident and had to undergo extensive reconstructive and rehabilitative oral surgery. Considering only the "prevailing charge" of physicians in the region when determining "reasonable charges" and not taking into account the customary charges of physicians offering similar services, carrier paid the lowest of the prevailing, customary, or actual charges. Medicare also refused to reimburse a physician for endodontic services; they were excluded from Medicare’s dental service coverage. The ALJ held that the physicians’ submitted charges were their customary charges, did not exceed the inflation-index charge, and were "reasonable charges" entitled to full reimbursement. Also, payment should be made for the endodontic services because they were secondary to beneficiary’s underlying medical condition and integral to the dental procedures she needed; the services should be allowed pursuant to 42 C.F.R. § 405.310(i).

Additional Information

Attorney Information
Claimant represented by Rural Legal Services of Tennessee, Inc., P.O. Box 5209, Oak Ridge, TN 37831.
Docket Date
1992-01-30 00:00:00+00:00

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