A bureaucratic Catch-22 is jeopardizing the health of a Staten Island man and thousands of other Medicaid recipients, a federal lawsuit alleges.
Frank Ciaramella, 57, has sued the state Health Department, alleging it is denying him replacement dentures and dental implants critical to his well-being.
Ciaramella suffers from end-stage renal disease, requiring dialysis three times a week, along with diabetes, hypertension and coronary artery disease, his class-action lawsuit alleges.
The civil complaint alleges Ciaramella needs dental implants and dentures to chew and eat the high-fiber foods he requires for proper nourishment. Because he isn't able to do so, he is "protein-malnourished" and more susceptible to disease, alleges the complaint, filed in Manhattan federal court.
"Mr. Ciaramella's dental needs are inextricably related to his medical conditions," the complaint maintains.
The state's Medicaid program categorically bans dental implants and strictly limits replacement dentures, the complaint alleges.
The program "completely ignore(s) the close connection between poor oral health and a range of other health problems," contends the complaint. "Poor oral health and tooth loss can lead to poor nutrition, which also compounds health problems. Poor nutrition, in turn, increases the odds of oral disease, thus trapping individuals in a vicious cycle."
The suit seeks an injunction ordering the Health Department to provide the plaintiffs with coverage for medically necessary dental services and from denying medically necessary dental coverage to Medicaid-eligible individuals.
It also requests eliminating the categorical ban on dental replacements and to provide all medically necessary dental coverage within a reasonable time period.
"New York State has a legal and moral obligation to provide comprehensive dental coverage to poor New Yorkers, and we look forward to arguing this in federal court," said Belkys Garcia, a lawyer with the Legal Aid Society which, along with the firm of Willkie Farr & Gallagher, is representing the plaintiffs.
In response to the suit, Gary Holmes, a Health Department spokesman, said 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."
"The Department of Health is committed to reviewing any preexisting policies and unique individual cases to determine if dental procedures or changes to coverage are warranted," said Holmes. "We will continue to work with affected individuals to ensure the state is being responsive to their needs."
In Ciaramella's case, his inability to chew food prevents him from following a diet prescribed for his renal disease, according to a published report in The New York Times. Consequently, his diet is carbohydrate heavy, and he's too overweight for a needed kidney transplant, the report said.
Ciaramella, whose street address is not listed in court papers, is on the transplant wait list.
His health problems are long-standing. He started dialysis in 2014, and by January 2015 had all of his teeth removed, said the complaint.
In 2016, he was fitted for and received upper and lower dentures. The upper dentures fit well, but the lower ones didn't, causing him "substantial discomfort," the complaint said.
Once, the lower dentures slid back into Ciaramella's mouth while he was eating, nearly choking him, the complaint said. As a result, he has been forced to abandon them.
Meanwhile, Ciaramella's upper dentures recently fell out of his mouth and were destroyed when a car ran over them.
He was deemed ineligible for replacement dentures until 2024, the complaint said.
Under the state's Medicaid program rules, dentures won't be replaced for eight years, even if lost, stolen or broken "unless there exists a serious health condition that has been verified and documented," said the complaint.
An oral surgeon told Ciaramella he doesn't have enough bone support for dentures and requires two dental implants to hold his dentures in place, the complaint said.
He applied for coverage for dental implants in August 2016 but was denied because the service was deemed not covered and not billable after placement of dentures, said the complaint.
"Dental implants, which would allow him to safely wear a bottom denture, are medically necessary for Mr. Ciaramella and would address his other serious health conditions," the complaint contends. "New York's denial of such care has trapped him in a cycle of poor health."
The suit alleges the denial of coverage for Ciaramella's dental implants violates the Medicaid Act, Americans with Disabilities Act, and Rehabilitation Act.
"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, but they also disregard the numerous side effects of those rules on thousands of low-income New Yorkers relying on Medicaid for dental care - including medical complications, social isolation and employability," said Mary Eaton, a partner at Willkie Farr & Gallagher.
There is a second plaintiff in the suit: Richard Palazzola, 60, of Suffolk County.
The complaint alleges his lower dentures were stolen in 2017 when he returned to his room in supportive housing for people with mental-health conditions.
Palazzola's dentist requested authorization for replacement dentures, but it was denied on the grounds the service is available under the program only once every eight years, said the complaint.