ACCESS TO DENTAL CARE FOR MEDICALLY COMPELLING CONDITIONS
1. Purpose. This Information Letter solicits the assistance of each facility Director in providing appropriate care for veteran patients having a medical condition negatively impacted by poor oral health, and provides information that may assist facilities in providing a consistent standard of dental care throughout the Veterans Health Administration (VHA).
2. Background
a. Although there is one legislative standard for dental eligibility, it has long been a concern that patients do not receive the same amount or extent of care at all Department of Veterans Affairs (VA) facilities across the country. In the past 7 years, dental care for the medically compelling dental patient, where poor oral health is negatively impacting a systemic illness, has significantly decreased.
b. While there are twenty-two Classifications of eligibility for dental care, dental Classifications I through VI define eligibility for approximately 90 percent of veterans treated in VA facilities. These Classifications, defined in VHA Handbook 1130.1, are:
(1) Classification I. Those having a service connected compensable dental disability or condition are eligible for any dental care, reasonably necessary to maintain oral health and masticatory function, including repeat care.
(2) Classification II. Those having service connected non-compensable dental conditions or disability shown to have been in existence at time of discharge or release from active duty may be authorized any treatment as reasonably necessary for the one-time correction of the service connected non-compensable condition.
(3) Classification II (a). Those having a service connected non-compensable dental condition or disability adjudicated as resulting from combat wounds or service trauma are eligible for repeat care for the service connected condition.
NOTE: Classification II (b) was discontinued by VHA Directive 2004-005.
(5) Classification III. Those having a dental condition professionally determined by VA to be currently aggravating a service connected medical condition are eligible for dental care to satisfactorily resolve the problem.
(6) Classification IV. Veterans whose service connected disabilities have been rated at 100 percent or who are receiving the 100 percent rate by reason of individual un-employability are eligible for any needed dental care, including repeat care.
(7) Classification V. A service connected, disabled veteran who has been approved by VA for vocational rehabilitation training and for whom an objective has been selected, or who is pursuing this training, may be provided limited dental care.
(8) Classification VI. Any veteran scheduled for admission or who is receiving outpatient care under Title 38 United States Code may receive dental care if the dental condition is clinically determined to be complicating a non-service connected medical condition currently under VA treatment.
c. In 2000, approximately 21 percent of all dental patients in the VA Health Care System were Classification III and VI patients, i.e., those with a compelling medical need for dental care. By 2007, this was reduced to 12 percent, largely as a result of competition for resources with the growing populations of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans and those with 100 percent service connection.
d. While the medically compelling Classification III or VI dental patient is fully eligible for limited dental treatment according to VA Regulations, there remains an inconsistent interpretation of eligibility guidelines which has resulted in inadequate access to care for some compelling medical patients.
3. Evaluation
a. Veterans with a medically compelling need for dental care may be treated as either a Classification III or VI, depending upon whether the medical condition is service connected.
b. The following conditions may infer a presumptive need for examination and appropriate treatment, as indicated. While this list is not meant to be all inclusive, other conditions need to be supported by contemporary clinical literature.
Heart valve replacement (pre-surgical).
Pre-surgical elimination or prevention of foci of infection.
Major orthopedic joint prosthesis (pre-surgical).
Pre-surgical elimination or prevention of foci of infection.
Poorly controlled diabetes with a HbA1c greater than 9 percent.
Elimination or prevention of foci of infection.
Organ transplantation (pre-surgical).
Pre-surgical elimination or prevention of foci of infection.
Severe immunocompromised status.
Elimination or prevention of foci of infection.
Induction of chemotherapy anticipated to result in significant immunosuppresion (to include adjunctive agents, e.g., infusion bisphosphonates for malignancy and osteoporosis).
Elimination or prevention of foci of infection.
Head and neck cancer requiring radiation to tooth bearing jaw structure.
Elimination or prevention of foci of infection.
4. Treatment
a. Classification III and VI patient groups need to receive care limited to the treatment of those dental conditions that are professionally determined by the examining or treating dentist to be aggravating or compromising a medical condition. The goal of care is improvement of the oral conditions that directly impact the medical condition. In general, this is meant to be the presurgical or pretreatment elimination of oral foci of infection. This generally includes dental caries, active periodontal disease, or acute and chronic dentoalveolar abscess. Restoration of function with prosthetic care is a desirable goal, but is resource driven. Comprehensive dental treatment is not routinely provided.
b. Dental treatment is generally limited to supportive periodontal therapy, non-cast restorative dentistry, oral surgical procedures, and endodontics; if dental care results in edentulation or significant compromise to speech or aesthetics, prosthetic rehabilitation may be authorized. Subsequent prosthetic care following the episode of care when the prosthesis is provided is the responsibility of the patient. With the exception of patients who have received radiation therapy to the maxilla or mandible, eligibility for each episode of care must be predicated on referral and application followed by a new evaluation.
5. Inquiries. Questions regarding this Information Letter may be directed to the Office of Dentistry in Patient Care Services at 202-461-6951.
Michael J. Kussman, MD, MS, MACP
Under Secretary for Health
DISTRIBUTION:
CO:
E-mailed 7/17/08
FLD:
VISN, MA, DO, OC, OCRO, and 200 – E-mailed 7/17/08
Question
Wings
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DEPARTMENT OF VETERANS AFFAIRS
Veterans Health Administration
Washington, DC 20420
IL 10-2008-010
In Reply Refer To: 113
July 14, 2008
UNDER SECRETARY FOR HEALTH’S INFORMATION LETTER
ACCESS TO DENTAL CARE FOR MEDICALLY COMPELLING CONDITIONS
1. Purpose. This Information Letter solicits the assistance of each facility Director in providing appropriate care for veteran patients having a medical condition negatively impacted by poor oral health, and provides information that may assist facilities in providing a consistent standard of dental care throughout the Veterans Health Administration (VHA).
2. Background
a. Although there is one legislative standard for dental eligibility, it has long been a concern that patients do not receive the same amount or extent of care at all Department of Veterans Affairs (VA) facilities across the country. In the past 7 years, dental care for the medically compelling dental patient, where poor oral health is negatively impacting a systemic illness, has significantly decreased.
b. While there are twenty-two Classifications of eligibility for dental care, dental Classifications I through VI define eligibility for approximately 90 percent of veterans treated in VA facilities. These Classifications, defined in VHA Handbook 1130.1, are:
(1) Classification I. Those having a service connected compensable dental disability or condition are eligible for any dental care, reasonably necessary to maintain oral health and masticatory function, including repeat care.
(2) Classification II. Those having service connected non-compensable dental conditions or disability shown to have been in existence at time of discharge or release from active duty may be authorized any treatment as reasonably necessary for the one-time correction of the service connected non-compensable condition.
(3) Classification II (a). Those having a service connected non-compensable dental condition or disability adjudicated as resulting from combat wounds or service trauma are eligible for repeat care for the service connected condition.
NOTE: Classification II (b) was discontinued by VHA Directive 2004-005.
(4) Classification II ©. Those who were Prisoners of War (POWs) are eligible for any needed dental care, including repeat care.
(5) Classification III. Those having a dental condition professionally determined by VA to be currently aggravating a service connected medical condition are eligible for dental care to satisfactorily resolve the problem.
(6) Classification IV. Veterans whose service connected disabilities have been rated at 100 percent or who are receiving the 100 percent rate by reason of individual un-employability are eligible for any needed dental care, including repeat care.
(7) Classification V. A service connected, disabled veteran who has been approved by VA for vocational rehabilitation training and for whom an objective has been selected, or who is pursuing this training, may be provided limited dental care.
(8) Classification VI. Any veteran scheduled for admission or who is receiving outpatient care under Title 38 United States Code may receive dental care if the dental condition is clinically determined to be complicating a non-service connected medical condition currently under VA treatment.
c. In 2000, approximately 21 percent of all dental patients in the VA Health Care System were Classification III and VI patients, i.e., those with a compelling medical need for dental care. By 2007, this was reduced to 12 percent, largely as a result of competition for resources with the growing populations of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans and those with 100 percent service connection.
d. While the medically compelling Classification III or VI dental patient is fully eligible for limited dental treatment according to VA Regulations, there remains an inconsistent interpretation of eligibility guidelines which has resulted in inadequate access to care for some compelling medical patients.
3. Evaluation
a. Veterans with a medically compelling need for dental care may be treated as either a Classification III or VI, depending upon whether the medical condition is service connected.
b. The following conditions may infer a presumptive need for examination and appropriate treatment, as indicated. While this list is not meant to be all inclusive, other conditions need to be supported by contemporary clinical literature.
Heart valve replacement (pre-surgical).
Pre-surgical elimination or prevention of foci of infection.
Major orthopedic joint prosthesis (pre-surgical).
Pre-surgical elimination or prevention of foci of infection.
Poorly controlled diabetes with a HbA1c greater than 9 percent.
Elimination or prevention of foci of infection.
Organ transplantation (pre-surgical).
Pre-surgical elimination or prevention of foci of infection.
Severe immunocompromised status.
Elimination or prevention of foci of infection.
Induction of chemotherapy anticipated to result in significant immunosuppresion (to include adjunctive agents, e.g., infusion bisphosphonates for malignancy and osteoporosis).
Elimination or prevention of foci of infection.
Head and neck cancer requiring radiation to tooth bearing jaw structure.
Elimination or prevention of foci of infection.
4. Treatment
a. Classification III and VI patient groups need to receive care limited to the treatment of those dental conditions that are professionally determined by the examining or treating dentist to be aggravating or compromising a medical condition. The goal of care is improvement of the oral conditions that directly impact the medical condition. In general, this is meant to be the presurgical or pretreatment elimination of oral foci of infection. This generally includes dental caries, active periodontal disease, or acute and chronic dentoalveolar abscess. Restoration of function with prosthetic care is a desirable goal, but is resource driven. Comprehensive dental treatment is not routinely provided.
b. Dental treatment is generally limited to supportive periodontal therapy, non-cast restorative dentistry, oral surgical procedures, and endodontics; if dental care results in edentulation or significant compromise to speech or aesthetics, prosthetic rehabilitation may be authorized. Subsequent prosthetic care following the episode of care when the prosthesis is provided is the responsibility of the patient. With the exception of patients who have received radiation therapy to the maxilla or mandible, eligibility for each episode of care must be predicated on referral and application followed by a new evaluation.
5. Inquiries. Questions regarding this Information Letter may be directed to the Office of Dentistry in Patient Care Services at 202-461-6951.
Michael J. Kussman, MD, MS, MACP
Under Secretary for Health
DISTRIBUTION:
CO:
E-mailed 7/17/08
FLD:
VISN, MA, DO, OC, OCRO, and 200 – E-mailed 7/17/08
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