WSR 03-15-129

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed July 22, 2003, 3:06 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 03-08-086 and 03-12-054.

Title of Rule: Part 3 of 4, chapter 388-535 WAC, Dental services, amending WAC 388-535-1240 Dentures, partial dentures, and overdentures; and new sections WAC 388-535-1255 Covered dental-related services -- Adults and 388-535-1265 Dental-related services not covered -- Adults.

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 WAC 388-535-1120 will be repealed.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 [2003], phone (360) 664-6094, TTY (360) 664-6178, e-mail fernanaax@dshs.wa.gov [fernaax@dshs.wa.gov].

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 fernaax@dshs.wa.gov 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 Unit

3271.4
AMENDATORY SECTION(Amending WSR 02-13-074, filed 6/14/02, effective 7/15/02)

WAC 388-535-1240   Dentures, ((partials)) partial dentures, and overdentures for children.   (1) Subject to the limitations in WAC 388-535-1100, the medical assistance administration (MAA) covers for children only one ((set of dentures)) maxillary denture and one mandibular denture per client in a ten-year period, and considers that set to be the first set. The exception to this is replacement dentures, which may be allowed as specified in subsection (4) of this section. Except as described in subsection (5) of this section, MAA does not require prior authorization for the first set of dentures. The first set of dentures may be any of the following:

(a) An immediate set (constructed prior to removal of the teeth);

(b) An initial set (constructed after the client has been without teeth for a period of time); or

(c) A final set (constructed after the client has received immediate or initial dentures).

(2) The first ((set of dentures)) maxillary denture and the first mandibular denture must be of the structure and quality to be considered the primary set. MAA does not cover transitional or treatment dentures.

(3) MAA covers partials (resin and cast base) once every five years, except as noted in subsection (4) of this section, and subject to the following limits:

(a) Cast base partials only when replacing three or more teeth per arch excluding wisdom teeth; and

(b) No partials are covered when they replace wisdom teeth only.

(4) Except as stated below, MAA does not require prior authorization for replacement dentures or partials when:

(a) The client's existing dentures or partials meet any of the following conditions. MAA requires prior authorization for replacement dentures or partials requested within one year of the seat date. The dentures or partials must be:

(i) No longer serviceable and cannot be relined or rebased; or

(ii) Damaged beyond repair.

(b) The client's health would be adversely affected by absence of dentures;

(c) The client has been able to wear dentures successfully;

(d) The dentures or partials meet the criteria of medically necessary; and

(e) The dentures are replacing a lost ((dentures)) maxillary denture and/or a mandibular denture, and the replacement set does not exceed MAA's limit of one set in a ten-year period as stated in subsection (1) of this section.

(5) MAA does not reimburse separately for laboratory and professional fees for dentures and partials. However, MAA may partially reimburse for these fees when the provider obtains prior authorization and the client:

(a) Dies;

(b) Moves from the state;

(c) Cannot be located; or

(d) Does not participate in completing the dentures.

(6) The provider must document in the client's medical or dental record:

(a) Justification for replacement of dentures;

(b) Charts of missing teeth, for replacement of partials; and

(c) Receipts for laboratory costs or laboratory records and notes.

(7) For billing purposes, the provider may use the impression date as the service date for dentures, including partials, only when:

(a) Related dental services including laboratory services were provided during a client's eligible period; and

(b) The client is not eligible at the time of delivery.

(8) For billing purposes, the provider may use the delivery date as the service date when the client is using the first set of dentures in lieu of noncovered transitional or treatment dentures after oral surgery.

(9) MAA includes the cost of relines and adjustments that are done within six months of the seat date in the reimbursement for the dentures.

(10) MAA covers one rebase in a five-year period; the dentures must be at least three years old.

(11) The requirements in this section also apply to overdentures.

[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, 388-535-1240, 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, 388-535-1240, filed 3/10/99, effective 4/10/99.]

ADULTS' DENTAL-RELATED SERVICES
NEW SECTION
WAC 388-535-1255   Covered dental-related services -- Adults.   (1) The medical assistance administration (MAA) pays for covered dental and dental-related services for adults listed in this section only when they are:

(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 adults, subject to the restrictions and limitations in this section and other applicable WAC:

(a) Medically necessary services for the identification of dental problems or the prevention of dental disease, subject to the limitations of this chapter.

(b) A comprehensive oral evaluation once per provider as an initial examination, that must include:

(i) A complete dental and medical history and a general health assessment;

(ii) A complete thorough evaluation of extra-oral and intra-oral hard and soft tissue; and

(iii) The evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, and oral cancer screening.

(c) Periodic oral evaluations once every six months to include a periodontal screening/charting at least once per year. There must be six months between the comprehensive oral evaluation and the first periodic oral evaluation.

(d) Limited oral evaluations only when the provider is not providing pre-scheduled dental services for the client. The limited oral evaluation must be:

(i) To provide limited or emergent services for a specific dental problem; and/or

(ii) To provide an evaluation for a referral.

(e) Radiographs, as follows:

(i) Intraoral, complete series (including bitewings), allowed only once in a three-year period;

(ii) Panoramic film, allowed only once in a three-year period and only for oral surgical purposes (see subsection (3) of this section for clients of the division of developmental disabilities);

(iii) Periapical radiographs as needed (periapical radiographs and bitewings taken on the same date of service cannot exceed MAA's fee for a complete intraoral series); and

(iv) Bitewings, up to four allowed every twelve months.

(f) Fluoride treatment as follows (see subsection (3) of this section for clients of the division of developmental disabilities):

(i) Topical application of fluoride gel or fluoride varnish for adults age nineteen through sixty-four with xerostomia (requires prior authorization); and

(ii) Topical application of fluoride gel or fluoride varnish for adults age sixty-five and older for:

(A) Rampant root surface decay; or

(B) Xerostomia.

(g) Oral prophylaxis treatment, which is:

(i) Allowed once every twelve months for adults age nineteen and older, including nursing facility clients, and for clients of the division of developmental disabilities as provided in subsection (3) of this section; and

(ii) Not allowed when oral prophylaxis treatment is performed on the same date of service as periodontal scaling and root planing, periodontal maintenance, gingivectomy, or gingivoplasty.

(h) Restoration of teeth and maintenance of dental health, subject to the limitations in WAC 388-535-1265 and as follows:

(i) Amalgam and composite restorations are allowed once for the same surface of the same tooth per client, per provider, subject to the following:

(A) Multiple restorations involving the proximal and occlusal surfaces of the same tooth are considered to be a single multisurface restoration. Payment is limited to that of a single multisurface restoration.

(B) Proximal restorations that do not involve the incisal angle in the anterior teeth are considered to be a two-surface restoration. Payment is limited to a two-surface restoration.

(C) Proximal restorations that involve the incisal angle are considered to be either a three- or four-surface restoration. All surfaces must be listed on the claim for payment.

(D) MAA pays for a maximum of six surfaces for a posterior tooth, which is allowed once per client, per provider, in a two-year period.

(E) MAA pays for a maximum of six surfaces for an anterior tooth, which is allowed once per client, per provider, in a two-year period.

(F) MAA pays for flowable composites as a restoration only when used:

(I) With a cavity preparation for a carious lesion that penetrates through the enamel;

(II) As a small Class I (occlusal) restoration;

(III) As a Class V (buccal or lingual) restoration.

(j) Endodontic (root canal) therapy for permanent anterior teeth only.

(k) Periodontal scaling and root planing, which is:

(i) Allowed for clients of the division of developmental disabilities as provided in subsection (3) of this section;

(ii) Allowed for clients age nineteen and older;

(iii) Allowed only when the client has radiographic evidence of periodontal disease. There must be supporting documentation in the client's record, including complete periodontal charting and a definitive periodontal diagnosis;

(iv) Allowed once per quadrant in a twenty-four month period;

(v) Allowed only when the client's clinical condition meets existing periodontal guidelines; and

(vi) Not allowed when performed on the same date of service as oral prophylaxis, periodontal maintenance, gingivectomy or gingivoplasty.

(l) Periodontal maintenance, which is:

(i) Allowed for clients of the division of developmental disabilities as provided in subsection (3) of this section;

(ii) Allowed for clients age nineteen and older;

(iii) Allowed only when the client has been previously treated for periodontal disease, including surgical or nonsurgical periodontal therapy;

(iv) Allowed when supporting documentation in the client's record includes a definitive periodontal diagnosis and complete periodontal charting;

(v) Allowed when the client's clinical condition meets existing periodontal guidelines;

(vi) Allowed when periodontal maintenance starts at least six months after completion of periodontal scaling and root planing or surgical treatment and paid only at six month intervals; and

(vii) Not allowed when the periodontal maintenance is performed on the same date of service as oral prophylaxis or periodontal scaling and root planing, gingivectomy, or gingivoplasty.

(m) Dentures and partial dentures according to WAC 388-535-1290.

(n) Simple extractions (includes local anesthesia, suturing, and routine postoperative care).

(o) Surgical extractions, subject to the following:

(i) Includes local anesthesia, suturing, and routine postoperative care; and

(ii) Requires documentation in the client's file to support soft tissue, partially bony, or completely bony extractions.

(p) Medically necessary oral surgery when coordinated with the client's managed care plan (if any).

(q) Palliative (emergency) treatment of dental pain, minor procedures, which is:

(i) Allowed once per client, per day.

(ii) Allowed only when performed on a different date from:

(A) Any other definitive treatment necessary to diagnose the emergency condition; and

(B) Root canal therapy.

(iii) Allowed only when a description of the service is included in the client's record.

(r) Behavior management that requires the assistance of one additional dental professional staff for clients of the division of developmental disabilities. See subsection (3) of this section.

(3) For clients of the division of developmental disabilities, MAA allows services as follows:

(a) Fluoride application, either varnish or gel, three times per calendar year;

(b) Prophylaxis or periodontal maintenance, three times per calendar year;

(c) Periodontal scaling and root planing, once every six months;

(d) Nitrous oxide;

(e) Behavior management that requires the assistance of one additional dental professional staff. A description of behavior management must be documented in the client's record;

(f) Panoramic radiographs; and

(g) General anesthesia or conscious sedation with parenteral or multiple oral agents when medically necessary for providing treatment.

(4) MAA covers dental services that are medically necessary and 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;

(b) Short stays when the procedure cannot be done in an office setting. See WAC 388-550-1100(6); and

(c) A hospital call, including emergency care, allowed one per day, per client, per provider.

(5) MAA covers general anesthesia and conscious sedation with parenteral or multiple oral agents for medically necessary dental services as follows:

(a) For treatment of clients who are eligible under the division of developmental disabilities.

(b) For oral surgery procedures.

(c) When justification for administering the general anesthesia instead of a lesser type of sedation is clearly documented in the client's record.

(d) When the anesthesia is administered by:

(i) An oral surgeon;

(ii) An anesthesiologist;

(iii) A dental anesthesiologist;

(iv) A Certified Registered Nurse Anesthetist (CRNA), if the performing dentist has a current conscious sedation permit or a current general anesthesia permit from the department of health (DOH); or

(v) A dentist who has a current conscious sedation permit or a current general anesthesia permit from DOH.

(e) When the provider meets the prevailing standard of care and at least the requirements in WAC 246-817-760, Conscious sedations with parenteral or multiple oral agents and WAC 246-817-770, General anesthesia.

(6) MAA pays for anesthesia services according to WAC 388-535-1350.

(7) MAA covers dental-related services for clients residing in nursing facilities or group homes as follows:

(a) Dental services must be requested by the client or the client's surrogate decision maker as defined in WAC 388-97-055, or a referral for services must be made by the attending physician, the director of nursing, or the nursing facility supervisor;

(b) Nursing facilities must provide dental-related necessary services according to WAC 388-97-012, Nursing facility care; and

(c) A bedside call at a nursing facility or group home is allowed once per day (not per client and not per facility), per provider. The bedside call must be requested by the client's physician.

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NEW SECTION
WAC 388-535-1265   Dental-related services not covered -- Adults.   (1) The medical assistance administration (MAA) does not cover dental-related services for adults described in subsection (2) of this section unless the services are included in an MAA waivered program.

(2) MAA does not cover the following dental-related services for adults:

(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) consider investigative or experimental on the date the services were provided.

(d) Coronal polishing.

(e) Fluoride treatments (gel or varnish) for adults, unless the clients are:

(i) Clients of the division of developmental disabilities;

(ii) Diagnosed with xerostomia, in which case the provider must request prior authorization; or

(iii) High-risk adults sixty-five and older. High-risk means the client has at least one of the following:

(A) Rampant root surface decay; or

(B) Xerostomia.

(f) Restorations for wear on any surface of any tooth without evidence of decay through the enamel or on the root surface.

(g) Flowable composites for interproximal or incisal restorations.

(h) Any permanent crowns, temporary crowns, or crown post and cores.

(i) Bridges, including abutment teeth and pontics.

(j) Root canal services for primary teeth.

(k) Root canal services for permanent teeth other than teeth six, seven, eight, nine, ten, eleven, twenty-two, twenty-three, twenty-four, twenty-five, twenty-six, and twenty-seven.

(l) Pulpotomy services for permanent teeth.

(m) Transitional or treatment dentures.

(n) Overdentures.

(o) Replacements for:

(i) Immediate maxillary or mandibular dentures;

(ii) Maxillary or mandibular partial dentures (resin); or

(iii) Complete maxillary or mandibular dentures in excess of one replacement in a ten-year period; or

(iv) Cast metal framework maxillary or mandibular partial dentures in excess of one replacement in a ten-year period.

(p) Rebasing, or adjustments of complete dentures and partial dentures.

(q) Tooth implants, including insertion, post-insertion, maintenance, and implant removal.

(r) Periodontal bone grafts or oral soft tissue grafts.

(s) Gingivectomy, gingivoplasty, or frenectomy/frenoplasty and other periodontal surgical procedures.

(t) Crown lengthening procedures.

(u) Orthotic appliances, including but not limited to, night guards, tempormandibular joint dysfunction (TMJ/TMD) appliances, and all other mouth guards.

(v) Any treatment of TMJ/TMD.

(w) Extraction of:

(i) Asymptomatic teeth;

(ii) Asymptomatic wisdom teeth; and

(iii) Surgical extraction of anterior teeth seven, eight, nine, ten, twenty-three, twenty-four, twenty-five, or twenty-six, which are considered simple extractions and paid as such.

(x) Alveoloplasty, alveoloectomy or troi/exostosis removal.

(y) Debridement of granuloma/cyst associated with tooth extraction.

(z) Cosmetic treatment or surgery, except as prior authorized by the department for medically necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness.

(aa) Nonemergent oral surgery for adults performed in an inpatient hospital setting, except:

(i) Nonemergent oral surgery is covered in an inpatient hospital setting for clients of the division of developmental disabilities when written prior authorization is obtained for the inpatient hospitalization; or

(ii) As provided in WAC 388-535-1080(4).

(bb) Dental supplies such as toothbrushes (manual, automatic, or electric), toothpaste, floss, or whiteners.

(cc) Dentist's time writing and calling in prescriptions or prescription refills.

(dd) Educational supplies.

(ee) Missed or canceled appointments.

(ff) Nonmedical equipment, supplies, personal or comfort items or services.

(gg) Provider mileage or travel costs.

(hh) Service charges or delinquent payment fees.

(ii) Supplies used in conjunction with an office visit.

(jj) Take-home drugs.

(kk) Teeth whitening.

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