NY Law Journal: Medicaid Patients Sue State NY Health Department to Secure Dental Coverage

Two Medicaid beneficiaries have filed a lawsuit against the state Department of Health for denying coverage of replacement dentures and dental implants.

The complaint, filed in the U.S. District Court for the Southern District of New York, claimed the state’s reasons for denying that coverage violate federal law concerning the Medicaid program.

The plaintiffs are being represented by Mary Eaton, a partner at Willkie Farr & Gallagher in Manhattan, and attorneys at the Legal Aid Society, including Belkys Garcia from the Law Reform Unit, Rebecca Novick from the Health Law Unit, and others. The Department of Health, as a state agency, is represented by the state Attorney General’s Office.

“What is important about this case is that New York state is denying medically necessary dental care to low-income New Yorkers and some of New York’s most vulnerable populations and it’s having an impact on people’s health and well-being and in some cases threatening their life,” Garcia said. “That practice is what we’re hoping to change.”

The state Department of Health defended the Medicaid program in a statement on Friday, saying the program is constantly being evaluated for ways it can be improved. Spokesman Gary Holmes said the agency is committed to evaluating each case individually to determine if coverage is warranted.

“New York state Medicaid offers some of the most comprehensive dental services in the country and is constantly evaluating its programs and making appropriate changes as they are needed,” Holmes said. “The Department of Health is committed to reviewing any pre-existing policies and unique individual cases to determine if dental procedures or changes to coverage are warranted. We will continue to work with affected individuals to ensure the state is being responsive to their needs.”

Plaintiffs Frank Ciaramella and Richard Palazzolo are Medicaid recipients who live in New York City and Suffolk County respectively. According to the complaint, both Ciaramella and Palazzolo were both approved for dentures by the state Medicaid program.

Both men either lost their dentures or weren’t able to use them because of events out of their control, according to the complaint. Ciaramella’s bottom dentures were so ill-fitting that he once choked on them, and his upper dentures were run over by a car after they fell out of his mouth. Palazzolo, who had partial lower dentures, came home one day to his room in a supportive housing facility to find his dentures had been stolen.

An oral surgeon told Ciaramella that he would need dental implants before he was given new dentures because he needed more bone support for the replacements, the lawsuit said. He was denied coverage of the implants because the service was not billable after placement of dentures, according to the complaint.

Both men were denied new dentures because a rule from New York’s Medicaid program requires eight years to pass before a new set is covered, the plaintiffs said.

Attorneys claim in the complaint that the state’s denial of coverage violated provisions of the federal Medicaid Act, including the comparability provision. That part of the law essentially said coverage for a service under Medicaid can not be denied for some individuals but allowed for others.

They argued that since other Medicaid recipients in New York are approved for dental implants, Ciaramella should be as well.

Attorneys also claimed the state’s Medicaid rules violate the availability provision of the Medicaid Act, which in part mandates that if a state chooses to cover dental services, that should include the treatment of “disease, injury or impairment that may affect the oral or general health of the beneficiary,” according to the complaint.

Both men, the lawsuit said, need new dentures to maintain their overall health. Ciaramella suffers from end-stage renal disease, diabetes, and was diagnosed as protein malnourished. Attorneys argued the state is making his condition worse by not providing coverage for dentures that would allow him to eat food with more protein. His renal condition prevents him from drinking protein shakes, they said.

Palazzolo also suffers from diabetes and has been diagnosed with bipolar disorder and depression, the complaint said. He’s had a hard time chewing since he lost his dentures, which has limited his diet, and also said his physical appearance without dentures has worsened his mental health.

Attorneys argued the overall health of both plaintiffs has been threatened without dentures, and that the state should be mandated to cover replacements to improve their well-being.

“The New York Medicaid program’s arbitrary restrictions on access to dental implants and replacement dentures plainly violate the Medicaid Act’s requirement to provide necessary care,” Eaton said. “But they also disregard the numerous side effects of those rules on thousands of low-income New Yorkers relying on Medicaid for their dental care—including medical complications, social isolation and employability.”

Similar arguments were used in Cruz v. Zucker, a case brought against the state Department of Health over Medicaid coverage for the treatment of gender dysphoria. Willkie Farr and the Legal Aid Society also worked on that case.

They argued in Cruz that the state was violating federal law by denying Medicaid coverage for transgender-related health services because those treatments were medically necessary. The state eventually promulgated and expanded rules allowing Medicaid coverage for gender dysphoria.

“In that case the Department of Health was providing all of these services for people who had a different diagnosis other than gender dysphoria,” Garcia said. “Specifically here the Medicaid program is offering dental implants to some people but not to everybody.”

The plaintiffs also claimed the state is violating the Americans with Disabilities Act by denying coverage to Ciaramella and Palazzolo, who both live with disabilities.

Attorneys are seeking a class action lawsuit in the case. U.S. District Judge J. Paul Oetken of the Southern District of New York is presiding over the case, according to filings.