SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Preproposal statement of inquiry was filed as WSR 03-08-086 and 03-12-054.
Title of Rule: Part 2 of 4, chapter 388-535 WAC, Dental services, amending WAC 388-535-1080 Covered dental-related services -- Children, 388-535-1100 Dental-related services not covered -- Children, 388-535-1200 Dental services requiring prior authorization, 388-535-1220 Obtaining prior authorization for dental services, and 388-535-1230 Crowns.
Purpose: To avoid federal penalties, the department is amending these rules to be HIPAA-compliant (P.L. 104-191) by October 16, 2003. To comply with requirements of the 2003-2005 State Omnibus Operating Budget (ESSB 5404), the department is incorporating into rule the 25% reduction in adult dental benefits.
Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530.
Statute Being Implemented: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530; ESSB 5404 (chapter 25, Laws of 2003 1st sp.s.).
Summary: See Purpose above.
Reasons Supporting Proposal: See Purpose above.
Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45533, Olympia, WA 98504, (360) 725-1342; Implementation and Enforcement: Gini Egan, P.O. Box 45506, Olympia, WA 98504, (360) 725-1580.
Name of Proponent: Department of Social and Health Services, governmental.
Rule is necessary because of federal law, Public Law 104-191 (Health Insurance Portability and Accountability Act of 1996).
Explanation of Rule, its Purpose, and Anticipated Effects: See Purpose above.
The purpose is to meet federal and state requirements, to incorporate rule changes to reflect the 25% reduction in dental-[related] services for adults, and to incorporate changes required by HIPAA.
The anticipated effect is compliance with federal and state requirements and easier to understand rules.
Proposal Changes the Following Existing Rules: Proposal incorporates state legislative changes in adult dental-related services and the changes required by HIPAA. The rules change and add to existing definitions, amend sections in and add new sections to chapter 388-535 WAC. WAC 388-535-1120 will be repealed.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rules, and, to the best of the department's knowledge, the rule will not place more than a minor economic impact on small businesses.
RCW 34.05.328 applies to this rule adoption. The department has determined that the proposed rule meets the definition of a "significant legislative rule." The department has analyzed the proposed amendments and concludes that the probable benefits are greater than the probable costs and has prepared a cost benefit analysis (CBA) memo regarding these rule changes. A copy of the CBA memo is available from Gini Egan, Division of Medical Management, Medical Assistance Administration, Department of Social and Health Services, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1580.
Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on August 26, 2003, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by August 22, 3003 , phone (360) 664-6094, TTY (360) 664-6178, e-mail email@example.com [firstname.lastname@example.org].
Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, mail to P.O. Box 45850, Olympia, WA 98504-5850, deliver to 4500 10th Avenue S.E., Lacey, WA, fax (360) 664-6185, e-mail email@example.com by 5:00 p.m., August 26, 2003.
Date of Intended Adoption: Not sooner than August 27, 2003.
July 17, 2003
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit3270.2
(a) Within the scope of an eligible client's medical care program;
(b) Medically necessary; and
(c) Within accepted dental or medical practice standards and are:
(i) Consistent with a diagnosis of dental disease or condition; and
(ii) Reasonable in amount and duration of care, treatment, or service.
(2) MAA covers the following dental-related services for eligible children:
(a) Medically necessary services for the identification of dental problems or the prevention of dental disease, subject to the limitations of this chapter;
(b) Oral health evaluations and assessments, which must be documented in the client's file according to WAC 388-502-0020, as follows:
(i) MAA allows a comprehensive oral evaluation once per provider as an initial examination, and it must include:
(A) An oral health and developmental history;
(B) An assessment of physical and oral health status; and
(C) Health education, including anticipatory guidance.
(ii) MAA allows a periodic oral ((
evaluation once every six months. Six months must elapse
between the comprehensive oral evaluation and the first
periodic oral evaluation.
(iii) MAA allows a limited oral ((
evaluation only when the provider performing the limited oral
evaluation is not providing pre-scheduled dental services for
the client. The limited oral evaluation must be:
(A) To provide limited or emergent services for a specific dental problem; or
(B) To provide an evaluation for a referral.
(c) Radiographs ((
(X rays) for children and adults,)) as
(i) Intraoral (complete series, including bitewings)
-)), allowed once in a three-year period;
(ii) Bitewings ((
-)), total of four allowed every twelve
(iii) Panoramic, for oral surgical purposes only, as follows:
(A) Not allowed with an intraoral complete series; and
(B) Allowed once in a three-year period, except for
preoperative or postoperative surgery cases. Preoperative ((
rays)) radiographs must be provided within fourteen days prior
to surgery, and postoperative (( X rays)) radiographs must be
provided within thirty days after surgery.
(d) Fluoride treatment (either gel or varnish, but not both) as follows for clients through age eighteen (additional applications require prior authorization):
For children through age eighteen,)) Topical
application of(( :
(A))) fluoride gel, once every six months; or
(B))) (ii) Topical application of fluoride varnish, up
to three times in a twelve-month period(( .
(ii) For adults age nineteen through sixty-four, topical application of fluoride gel or varnish for xerostomia only; this requires prior authorization.));
(iii) See subsection (3) of this section for clients of
the division of developmental disabilities((
(iii) For adults age sixty-five and older, topical application of fluoride gel or varnish for only:
(A) Rampant root surface decay; or
(e) Sealants for children only, once per tooth in a three-year period for:
(i) The occlusal surfaces of:
(A) Permanent teeth two, three, fourteen, fifteen, eighteen, nineteen, thirty, and thirty-one only; and
(B) Primary teeth A, B, I, J, K, L, S, and T only.
(ii) The lingual pits of teeth seven and ten; and
(iii) Teeth with no decay.
(f) Prophylaxis treatment, which is allowed:
Once every twelve months for adults age nineteen
and older, including nursing facility clients;
(ii))) Once every six months for children age eight through eighteen;
(iii))) (ii) Only as a component of oral hygiene
instruction for children through age seven; and
(iv))) (iii) For clients of the division of
developmental disabilities, see subsection (3) of this
(g) Space maintainers, for children through age eighteen only, as follows:
(i) Fixed (unilateral type), one per quadrant;
(ii) Fixed (bilateral type), one per arch; and
(iii) Recementation of space maintainer, once per quadrant or arch.
(h) Amalgam or composite restorations, as follows:
(i) Once in a two-year period; and
(ii) For the same surface of the same tooth.
(i) Crowns as described in WAC 388-535-1230, Crowns;
(j) Restoration of teeth and maintenance of dental health, subject to limitations of WAC 388-535-1100 and as follows:
(i) Multiple restorations involving the proximal and occlusal surfaces of the same tooth are considered to be a multisurface restoration, and are reimbursed as such; and
(ii) Proximal restorations that do not involve the incisal angle in the anterior tooth are considered to be a two-surface restoration, and are reimbursed as such;
(k) Endodontic (root canal) therapies for permanent teeth except for wisdom teeth;
(l) Therapeutic pulpotomies, once per tooth, on primary teeth only;
(m) Pulp vitality test, as follows:
(i) Once per day (not per tooth);
(ii) For diagnosis of emergency conditions only; and
(iii) Not allowed when performed on the same date as any other procedure, with the exception of an emergency examination or palliative treatment.
(n) Periodontal scaling and root planing as follows:
For clients age nineteen and older only.)) See
subsection (3) of this section for clients of the division of
(ii) Only when the client has radiographic (X ray) evidence of periodontal disease. There must be supporting documentation, including complete periodontal charting and a definitive periodontal diagnosis;
(iii) Once per quadrant in a twenty-four month period; and
(iv) Not allowed when performed on the same date of
service as ((
adult)) prophylaxis, gingivectomy, or
(o) Subject to WAC 388-535-1240 and as follows, complete and partial dentures, and necessary modifications, repairs, rebasing, relining, and adjustments of dentures (includes partial payment in certain situations for laboratory and professional fees for dentures and partials as specified in WAC 388-535-1240(5)). MAA covers:
(i) One set of dentures per client in a ten-year period, with the exception of replacement dentures which may be allowed as specified in WAC 388-535-1240(4); and
(ii) Partials as specified in WAC 388-535-1240(2), once every five years.
(p) Complex orthodontic treatment for severe handicapping dental needs as specified in chapter 388-535A WAC, Orthodontic services;
(q) Occlusal orthotic appliance for temporomandibular joint disorder (TMJ/TMD) or bruxism, one in a two-year period;
(r) Medically necessary oral surgery when coordinated with the client's managed care plan (if any);
(s) Dental services or treatment necessary for the relief of pain and infections, including removal of symptomatic wisdom teeth. MAA does not cover routine removal of asymptomatic wisdom teeth without justifiable medical indications;
(t) Behavior management for ((
children)) clients through
age eighteen only, whose documented behavior requires the
assistance of more than one additional dental professional
staff to protect the client from self-injury during treatment.
See subsection (3) of this section for clients of the
division of developmental disabilities.
(u) Nitrous oxide for children through age eighteen only, when medically necessary. See subsection (3) of this section for clients of the division of developmental disabilities.
(v) Professional visits, as follows:
(i) Bedside call at a nursing facility or residence, at the physician's request, allowed - one per day (see subsection (7) of this section).
(ii) Hospital call, including emergency care ((
allowed one per day.
(w) Emergency palliative treatment, as follows:
(i) Allowed only when no other definitive treatment is performed on the same day; and
(ii) Documentation must include tooth designation and a brief description of the service.
(3) For clients of the division of developmental disabilities, MAA allows services as follows:
(a) Fluoride application, either varnish or gel((
not both -)), allowed three times per calendar year;
(b) Periodontal scaling and root planing ((
once every six months;
(c) Prophylaxis ((
-)), allowed three times per calendar
(d) Nitrous oxide;
(e) Behavior management that requires the assistance of more than one additional dental professional staff and the use of advanced behavior techniques; and
(f) Panoramic radiographs, with documentation that behavior management is required.
(4) MAA covers medically necessary services provided in a hospital under the direction of a physician or dentist for:
(a) The care or treatment of teeth, jaws, or structures directly supporting the teeth if the procedure requires hospitalization; and
(b) Short stays when the procedure cannot be done in an office setting. See WAC 388-550-1100(6), Hospital coverage.
(5) MAA covers anesthesia for medically necessary services as follows:
(a) The anesthesia must be administered by:
(i) An oral surgeon;
(ii) An anesthesiologist;
(iii) A dental anesthesiologist;
(iv) A Certified Registered Nurse Anesthetist (CRNA); or
(iv))) (v) A general dentist who has a current
conscious sedation permit from the department of health (DOH).
(b) MAA ((
reimburses)) pays for anesthesia services
(( per)) according to WAC 388-535-1350.
(6) For clients residing in nursing facilities or group homes:
(a) Dental services must be requested by the client or a referral for services made by the attending physician, the director of nursing or the nursing facility supervisor, or the client's legal guardian;
(b) Mass screening for dental services of clients residing in a facility is not permitted; and
(c) Nursing facilities must provide dental-related
necessary services ((
per)) according to WAC 388-97-012,
Nursing facility care.
(7) A request to exceed stated limitations or other restrictions on covered services is called a limitation extension (LE), which is a form of prior authorization. MAA evaluates and approves requests for LE for dental-related services when medically necessary, under the provisions of WAC 388-501-0165.
[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1080, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1080, filed 3/10/99, effective 4/10/99.]
(a) Required by a physician as a result of an EPSDT screen as provided under chapter 388-534 WAC; or
(b) Included in an MAA waivered program((
(c) Part of one of the Medicare programs for qualified Medicare beneficiaries (QMB) except for QMB-only, which is not covered)).
(2) MAA does not cover the following services for children:
(a) Any service specifically excluded by statute;
(b) More costly services when less costly, equally effective services as determined by the department are available;
(c) Services, procedures, treatment, devices, drugs, or application of associated services which the department or the Centers for Medicare and Medicaid Services (CMS) (formerly known as the Health Care Financing Administration (HCFA)) consider investigative or experimental on the date the services were provided;
(d) Routine fluoride treatments (gel or varnish) ((
adults)) for clients age eighteen through twenty, unless the
(i) Clients of the division of developmental disabilities; or
(ii) Diagnosed with xerostomia, in which case the
provider must request prior authorization((
(iii) High-risk adults sixty-five and over. High-risk means the client has at least one of the following:
(A) Rampant root surface decay; or
(e) Crowns, as follows:
(i) For wisdom and peg teeth;
(ii) Laboratory processed crowns for posterior teeth;
(iii) Temporary crowns, including stainless steel crowns placed as temporary crowns; and
(iv) Post and core for crowns.
(f) Root canal services for primary or wisdom teeth;
(g) Root planing ((
for children)), unless they are
clients of the division of developmental disabilities;
(i) Transitional or treatment dentures;
(j) Teeth implants, including follow up and maintenance;
(k) Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness;
(l) Porcelain margin extensions (also known as crown lengthening), due to receding gums;
(m) Extraction of asymptomatic teeth;
(n) Minor bone grafts;
(o) Nonemergent oral surgery ((
for adults)) performed in
an inpatient hospital setting, except for the following:
(i) For clients of the division of developmental disabilities, or for children eighteen years of age or younger whose surgeries cannot be performed in an office setting. This requires written prior authorization for the inpatient hospitalization; or
(ii) As provided in WAC 388-535-1080(4).
(p) Dental supplies such as toothbrushes (manual, automatic, or electric), toothpaste, floss, or whiteners;
(q) Dentist's time writing prescriptions or calling in prescriptions or prescription refills to a pharmacy;
(r) Educational supplies;
(s) Missed or canceled appointments;
(t) Nonmedical equipment, supplies, personal or comfort items or services;
(u) Provider mileage or travel costs;
(v) Service charges or delinquent payment fees;
(w) Supplies used in conjunction with an office visit;
(x) Take-home drugs;
(y) Teeth whitening; or
(z) Restorations for anterior or posterior wear with no evidence of decay.
(3) MAA evaluates a request for any service that is listed as noncovered under the provisions of WAC 388-501-0165.
[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1100, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1100, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1100, filed 12/6/95, effective 1/6/96.]
(1) Nonemergent inpatient hospital dental admissions as described under WAC 388-535-1100 (2)(o) and 388-550-1100(1);
(2) Crowns as described in WAC 388-535-1230;
(3) Dentures as described in WAC 388-535-1240; and
Routine fluoride treatment (gel or varnish) for
adults age nineteen through sixty-four who are diagnosed with
(5))) Selected procedures identified by the medical
assistance administration (MAA) and published in its current
dental billing instructions((
, which are available from MAA in
[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1200, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1200, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1200, filed 12/6/95, effective 1/6/96.]
(1) MAA requires a dental provider who is requesting prior authorization to submit sufficient objective clinical information to establish medical necessity. The request must be submitted in writing on an American Dental Association (ADA) claim form, which may be obtained by writing to the American Dental Association, 211 East Chicago Avenue, Chicago, Illinois 60611. The request must include at least all of the following:
(a) Physiological description of the disease, injury, impairment, or other ailment;
X ray(s))) Radiographs;
(c) Treatment plan;
(d) Study model, if requested; and
(e) Photographs, if requested.
(2) MAA authorizes requested services that meet the criteria in WAC 388-535-1080.
(3) MAA denies a request for dental services when the requested service is:
(a) Not medically necessary; or
(b) A service, procedure, treatment, device, drug, or application of associated service which the department or the Centers for Medicare and Medicaid Services (CMS) (formerly known as the Health Care Financing Administration (HCFA)) consider investigative or experimental on the date the service is provided.
(4) MAA may require second opinions and/or consultations before authorizing any procedure.
(5) Authorization is valid only if the client is eligible for covered services on the date of service.
[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1220, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1220, filed 3/10/99, effective 4/10/99.]
(a) Stainless steel. MAA considers these as permanent crowns, and does not cover them as temporary crowns; and
(b) Nonlaboratory resin for primary anterior teeth.
(2) MAA does not cover laboratory-processed crowns for posterior teeth.
(3) MAA requires prior authorization for the following
crowns, which are limited to single restorations for permanent
(upper and lower))) maxillary and mandibular teeth
seven, eight, nine, ten, eleven, twenty-two, twenty-three,
twenty-four, twenty-five, twenty-six, and twenty-seven:
(a) Resin (laboratory);
(b) Porcelain with ceramic ((
(c) Porcelain fused to high noble metal;
(d) Porcelain fused to predominantly base metal; and
(e) Porcelain fused to noble metal.
(4) Criteria for covered crowns as described in subsections (1) and (3) of this section:
(a) Crowns may be authorized when the crown is medically necessary.
(b) Coverage is based upon a supportable five-year prognosis that the client will retain the tooth if the tooth is crowned. The provider must submit the following client information:
(i) The overall condition of the mouth;
(ii) Oral health status;
(iii) Client maintenance of good oral health status;
(iv) Arch integrity; and
(v) Prognosis of remaining teeth (that is, no more involved than periodontal case type II).
(c) Anterior teeth must show traumatic or pathological destruction to loss of at least one incisal angle.
(5) The laboratory processed crowns described in subsection (3) are covered:
(a) Only when a lesser service will not suffice because of extensive coronal destruction, and treatment is beyond intracoronal restoration;
(b) Only once per permanent tooth in a five-year period;
(c) For endodontically treated anterior teeth only after
satisfactory completion of the root canal therapy.
Post-endodontic treatment ((
X-rays)) radiographs must be
submitted for prior authorization of these crowns.
(6) MAA reimburses only for covered crowns as described in subsections (1) and (3) of this section. The reimbursement is full payment; all of the following are included in the reimbursement and must not be billed separately:
(a) Tooth and soft tissue preparation;
(b) Amalgam or acrylic build-ups;
(c) Temporary restoration;
(d) Cement bases;
(e) Insulating bases;
(g) Seating; and
(h) Local anesthesia.
[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1230, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520. 01-07-077, § 388-535-1230, filed 3/20/01, effective 4/20/01. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1230, filed 3/10/99, effective 4/10/99.]