## Facts

- Floyd Wood, a Medicare enrollee, required heart valve replacement surgery.
- Wood had severe periodontal disease that posed a significant risk of bacterial infection to an implanted artificial heart valve.
- Wood’s physicians required elimination of the dental infection before proceeding with valve surgery.
- A dentist extracted 14 teeth and performed jaw recontouring to prepare for future dentures.
- Wood later underwent the heart valve replacement; the surgeon stated he would not have operated without the pre-surgery extractions due to infection risk.
- The dentist submitted a Medicare Part B claim for $1,156 for the dental services.
- A Medicare carrier denied coverage as excluded dental services; administrative review (hearing officer, ALJ, and the Secretary’s final decision) upheld the denial.
- The district court upheld the agency decision, and Wood appealed.

## Issues

1. Whether Medicare Part B covers dental extractions and jaw recontouring when medically necessary to enable and protect the success of a covered heart valve replacement surgery.
2. Whether the statutory and regulatory exclusion for services connected to the care, treatment, removal, or replacement of teeth (and supporting structures) permits an exception for dental procedures integral to a covered medical procedure.

## Decision

- The Seventh Circuit affirmed the district court’s judgment upholding the Secretary’s denial of Part B reimbursement.
- The court held the extractions and jaw recontouring were “services in connection with” the removal or treatment of teeth and supporting structures within the Medicare dental exclusion.
- The court rejected the argument that medical necessity for a covered surgery creates an implied exception to the dental-services exclusion.
- The court noted the agency recognized only narrow, expressly delineated exceptions (e.g., jaw-radiation preparation, certain same-physician combined procedures, and specified transplant-related inpatient dental examinations), none of which applied.
- The administrative determination that the claim involved excluded dental services was supported by substantial evidence.

## Legal Principles

- Medicare Part B does not cover all medically necessary services; coverage depends on whether the service falls within covered benefit categories and is not subject to a statutory or regulatory exclusion.
- Dental services connected to the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth are categorically excluded absent an applicable enumerated exception.
- A prerequisite relationship to a covered medical procedure does not convert an excluded dental service into a covered service.
- Courts generally defer to the Secretary’s reasonable interpretation and administration of the Medicare statute and implementing regulations.
- Agency fact-finding and application of Medicare coverage rules are upheld if supported by substantial evidence.

## Conclusion

The court upheld the denial of Medicare Part B reimbursement for pre-surgical dental extractions and jaw recontouring, ruling that the dental-services exclusion controlled even though the procedures were medically necessary to permit safe performance of covered heart valve replacement surgery and no recognized exception applied.


Wood v. Thompson, 246 F.3d 1026 (7th Cir. 2001)