Date of Adoption: July 29, 2003.

     Purpose: To comply with requirements of the 2003-2005 State Omnibus Operating Budget, effective July 1, 2003, the department is incorporating, into emergency rule the 25% reduction in adult dental benefits. The timeframe for implementing the budget does not allow the department to implement the necessary reductions through the regular rule-making process.

     This order includes adoption of new WAC 388-535-1255, 388-535-1265, 388-535-1270, 388-535-1280, and 388-535-1290.

     Citation of Existing Rules Affected by this Order: Repealing WAC 388-535-1120; and amending WAC 388-535-1050, 388-535-1060, 388-535-1065, 388-535-1070, 388-535-1080, 388-535-1100, 388-535-1200, 388-535-1220, 388-535-1230, 388-535-1240, 388-535-1350, 388-535-1400, and 388-535-1450.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.530.

     Other Authority: Section 209, Part II, chapter 25, Laws of 2003 1st sp.s., (the 2003-2005 State Omnibus Operating Budget, ESSB 5404).

     Under RCW 34.05.350 the agency for good cause finds that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.

     Reasons for this Finding: In adopting chapter 25, Laws of 2003 1st sp.s., the legislature reduced funding for adult dental benefits by 25%. These emergency rules are needed to carry out the legislature's directive while the department adopts permanent rules. Proposed rules have been filed and a public hearing is scheduled for August 26, 2003.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 5, Amended 13, Repealed 1.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 5, Amended 13, Repealed 1.
     Effective Date of Rule: August 1, 2003.

July 29, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     "Access to baby and child dentistry (ABCD)" is a program to increase access to dental services in targeted areas for Medicaid eligible infants, toddlers, and preschoolers up through the age of five. See WAC 388-535-1300 for specific information.

     "Adult" for the general purposes of the medical assistance administration's (MAA) dental program, means a client twenty-one years of age or older (MAA's payment structure changes at age nineteen, which affects specific program services provided to adults or children).

     "American Dental Association (ADA)" is a national organization for dental professionals and dental societies.

     "Anterior" means teeth and tissue in the front of the mouth.

     (1) "((Lower)) Mandibular anterior teeth," - incisors and canines: permanent teeth twenty-two, twenty-three, twenty-four, twenty-five, twenty-six, and twenty-seven; and primary teeth M, N, O, P, Q, and R.

     (2) "((Upper)) Maxillary anterior teeth," - incisors and canines: permanent teeth six, seven, eight, nine, ten, and eleven; and primary teeth C, D, E, F, G, and H..

     "Asymptomatic" means having or producing no symptoms.

     "Base metal" means dental alloy containing little or no precious metals.

     "Behavior management" means managing the behavior of a developmentally disabled client ((during)) or a client age eighteen or younger to facilitate the delivery of dental treatment ((using)) with the assistance of one additional dental professional staff((, and professionally accepted restraints or sedative agent, to protect the client from self-injury)).

     "By report" - a method of ((payment for a covered service, supply, or equipment which:

     (1) Has no maximum allowable established by MAA,

     (2) Is a variation on a standard practice, or

     (3) Is rarely provided)) reimbursement in which MAA determines the amount it will pay for a service when the rate for that service is not included in MAA's published fee schedules. Upon request the provider must submit a "report" which describes the nature, extent, time, effort and/or equipment necessary to deliver the service.

     "Caries" means tooth decay through the enamel or decay of the root surface.

     "Child" for the general purposes of the medical assistance administration's (MAA) dental program, means a client twenty years of age or younger. (MAA's payment structure changes at age nineteen, which affects specific program services provided to children or adults.)

     "Comprehensive oral evaluation" means a thorough evaluation and recording of ((the)) a client's dental and medical history to include extra-oral and intra-oral hard and soft tissues, dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft ((tissues in and around the mouth, including the evaluation and recording of the client's dental and medical history and a general health assessment)) tissue anomalies, and oral cancer screening.

     "Conscious sedation" is a drug-induced depression of consciousness during which clients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, spontaneous ventilation is adequate, and cardiovascular function is usually maintained.

     "Coronal" is the portion of a tooth that is covered by enamel, and is separated from the root or roots by a slightly constricted region, known as the cemento-enamel junction.

     "Coronal polishing" is a procedure limited to the removal of plaque and stain from exposed tooth surfaces.

     "Crown (((artificial)))" means a restoration covering or replacing the major part, or the whole of, the clinical crown of a tooth.

     "Current dental terminology (CDT), third edition (CDT-3)," a systematic listing of descriptive terms and identifying codes for reporting dental services and procedures performed by dental practitioners. CDT is published by the Council on Dental Benefit Programs of the American Dental Association (ADA).

     "Current procedural terminology (CPT) 2002 (CPT 2002)," means a description of medical procedures and is available from the American Medical Association of Chicago, Illinois.

     "Decay" See "caries".

     "Deep sedation" is a drug-induced depression of consciousness during which a client cannot be easily aroused, ventilatory function may be impaired, but the client responds to repeated or painful stimulation.

     "Dental general anesthesia" ((means the use of agents to induce loss of feeling or sensation, a controlled state of unconsciousness, in order to allow dental services to be rendered to the client.)) See "general anesthesia."

     "Dentures" ((are a set of artificial teeth, including overdentures. See WAC 388-535-1240 for specific information)) means an artificial replacement for natural teeth and adjacent tissues, and includes complete dentures, immediate dentures, overdentures, and partial dentures.

     "Endodontic" means ((a)) disease and injuries to the pulp requiring root canal ((treatment)) therapy and related follow-up.

     "EPSDT" means the department's early and periodic screening, diagnosis, and treatment program for clients twenty years of age and younger as described in chapter 388-534 WAC.

     "Extraction" See "simple extraction" and "surgical extraction."

     "Flowable composite resin" is a light-cured, low viscosity composite resin that is used in cervical lesions and other small, low stress bearing restorations.

     "Fluoride varnish or gel" means a substance containing dental fluoride, applied to teeth.

     "General anesthesia" is a drug-induced loss of consciousness during which clients are not arousable even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Clients may require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

     "High nobel metal" means a dental alloy containing at least sixty percent pure gold.

     "Limited oral evaluation" means an evaluation limited to a specific oral health condition or problem. Typically a client receiving this type of evaluation has a dental emergency, such as trauma or acute infection.

     "Limited visual oral assessment" means a screening of the hard and soft tissues in the mouth.

     "Major bone grafts" means a transplant of solid bone tissue(s).

     "Medically necessary" see WAC 388-500-0005.

     "Minor bone grafts" means a transplant of nonsolid bone tissue(s), such as powdered bone, buttons, or plugs.

     "Noble metal" means a dental alloy containing at least twenty-five percent but less than sixty percent pure gold.

     "Oral evaluation" ((is a comprehensive oral health and developmental history; an assessment of physical and oral health development and nutritional status; and health education, including anticipatory guidance)) See "Comprehensive oral evaluation".

     (("Oral health assessment or screening" means a screening of the hard and soft tissues in the mouth.))

     "Oral hygiene instruction" means instruction for home oral hygiene care, such as tooth brushing techniques or flossing.

     (("Oral health status" refers to the client's risk or susceptibility to dental disease at the time an oral evaluation or assessment is done by a dental practitioner. This risk is designated as low, moderate or high based on the presence or absence of certain indicators.))

     "Oral prophylaxis" means the preventive dental procedure of scaling and polishing which includes removal of calculus, soft deposits, plaque, and stains.

     "Partials" or "partial dentures" means a removable appliance replacing ((one or more)) missing teeth in one ((jaw)) arch, and receiving its support and retention from both the underlying tissues and some or all of the remaining teeth. ((See WAC 388-535-1240 for specific information.))

     "Periodic oral evaluation" means an evaluation performed on a patient of record to determine any changes in the client's dental or medical status since a previous comprehensive or periodic evaluation. This includes a periodontal charting at least once per year.

     "Periodontal maintenance" means a procedure for clients who have previously been treated for periodontal disease and starts after completion of active (surgical or nonsurgical) periodontal therapy. It includes removal of the supra and subgingival microbial flora and calculus.

     "Periodontal scaling and root planing" means instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus, microbial flora, and bacterial toxins.

     "Posterior" means teeth and tissue towards the back of the mouth. ((Specifically, only these permanent teeth:))

     (1) "Mandibular posterior teeth" ((one, two, three, four, five, twelve, thirteen, fourteen, fifteen, sixteen,)) - molars and premolars: permanent teeth seventeen, eighteen, nineteen, twenty, twenty-one, twenty-eight, twenty-nine, thirty, thirty-one, and thirty-two; and primary teeth K, L, S, and T.

     (2) "Maxillary posterior teeth" - molars and premolars: permanent teeth one, two, three, four, five, twelve, thirteen, fourteen, fifteen, and sixteen; and primary teeth A, B, I, and J.

     "Proximal" means the surface of the tooth near or next to the adjacent tooth.

     "Reline" means to resurface the tissue side of a denture with new base material or soft tissue conditioner in order to achieve a more accurate fit.

     "Root canal" is a portion of the pulp cavity inside the root of a tooth and the chamber within the root of the tooth that contains the pulp.

     "Root canal therapy" is the treatment of disease and injuries of the pulp and associated periradicular conditions.

     "Root planing" ((is)) means a procedure ((designed)) to remove microbial flora, bacterial toxins, calculus, and diseased cementum or dentin ((from the teeth's)) on the root surfaces and in the pockets.

     "Scaling" ((means the removal of calculous material from the exposed tooth surfaces and that part of the teeth covered by the marginal gingiva)) is a procedure to remove plaque, calculus, and stain deposits from tooth surfaces.

     "Sealant" is a material applied to teeth to prevent dental caries.

     "Simple extraction" means routine removal of tooth structure.

     "Standard of care" means what reasonable and prudent practitioners would do in the same or similar circumstances.

     "Surgical extraction" means removal of tooth structure with cutting of gingiva and bone, including soft tissue extractions, partial boney extractions, and complete boney extractions.

     "Symptomatic" means having symptoms (e.g., pain, swelling, and infection).

     "Temporomandibular joint dysfunction (TMJ/TMD)" means an abnormal functioning of the temporomandibular joint or other areas secondary to the dysfunction.

     "Therapeutic pulpotomy" means the surgical removal of a portion of the pulp (inner soft tissue of a tooth), to retain the healthy remaining pulp.

     "Usual and customary" means the fee that the provider usually charges non-Medicaid customers for the same service or item. This is the maximum amount that the provider may bill MAA.

     "Wisdom teeth" means teeth one, sixteen, seventeen, and thirty-two.

     "Xerostomia" means a dryness of the mouth.

[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, § 388-535-1050, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090. 01-02-076, § 388-535-1050, filed 12/29/00, effective 1/29/01. 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, § 388-535-1050, 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), § 388-535-1050, filed 12/6/95, effective 1/6/96.]

     Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.((COVERAGE))
AMENDATORY SECTION(Amending WSR 02-13-074, filed 6/14/02, effective 7/15/02)

WAC 388-535-1060   Clients who are eligible for dental-related services.   (((1) Subject to the specific limitations described in WAC 388-535-1080, Covered services,)) The following clients who receive services under the ((following)) medical assistance programs listed in this section are eligible for ((the)) covered dental-related services ((described in this chapter)), subject to the restrictions and specific limitations described in this chapter and other applicable WAC:

     (1) Children eligible for the:

     (a) Categorically needy program (CN or CNP);

     (b) Children's health insurance program (CNP-CHIP); and

     (c) ((Qualified Medicare beneficiary (CNP-QMB);

     (d))) Limited casualty program((/)) - medically needy program (LCP-MNP)((;

     (e) Medically needy program - qualified Medicare beneficiary (MNP-QMB);

     (f) Children's health (the state-funded only program) through September 30, 2002 only; and

     (g) Pregnant undocumented aliens.

     (2) Clients who receive services under the following state-funded only programs are covered as described in WAC 388-535-1120:

     (a) General assistance unemployable (GAU); and

     (b) Alcohol and drug abuse treatment and support act (ADATSA).

     (3) Clients who receive services under the medically indigent (MI) program are covered for only those medical conditions that are acute and emergent and treated in a hospital)).

     (2) Adults eligible for the:

     (a) Categorically needy program (CN or CNP); and

     (b) Limited casualty program - medically needy program (LCP-MNP).

     (3) Clients eligible for medical care services under the following state-funded only programs are eligible only for the limited dental-related services described in WAC 388-535-1065:

     (a) General assistance - Unemployable (GA-U); and

     (b) General assistance - Alcohol and Drug Abuse Treatment and Support Act (ADATSA) (GA-W).

     (4) Clients who are enrolled in a managed care plan are eligible for medical assistance administration (MAA)-covered dental services that are not covered by their plan, under fee-for-service, subject to the provisions of chapter 388-535 WAC and other applicable WAC.

[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, § 388-535-1060, 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, § 388-535-1060, filed 3/10/99, effective 4/10/99.]

     (a) General assistance unemployable (GA-U); and

     (b) Alcohol and Drug Abuse Treatment and Support Act (ADATSA) (GA-W).

     (2) The medical assistance administration (MAA) covers the dental-related services described and limited in this chapter for clients eligible for GA-U or GA-W only when those services are provided as part of a medical treatment for apical abscess verified by clinical examination, and treated by:

     (a) Open and drain palliative treatment;

     (b) Tooth extraction; or

     (c) Root canal therapy for permanent anterior teeth only.

[]

     (a) Persons currently licensed by the state of Washington to:

     (i) Practice dentistry or specialties of dentistry;

     (ii) ((Practice medicine and osteopathy for:

     (A) Oral surgery procedures; or

     (B) Providing fluoride varnish under EPSDT;

     (iii))) Practice as dental hygienists;

     (((iv) Provide denture services;

     (v) Practice anesthesia; or

     (vi) Provide))

     (iii) Practice as denturists;

     (iv) Practice anesthesia by:

     (A) Providing conscious sedation((, when certified by the department of health and when providing that service in dental offices for dental treatments)) with parenteral or multiple oral agents, deep sedation, or general anesthesia as an anesthesiologist or dental anesthesiologist;

     (B) Providing conscious sedation with parenteral or multiple oral agents, deep sedation, or general anesthesia as a Certified Registered Nurse Anesthetist (CRNA), when the performing dentist has the appropriate conscious sedation permit or general anesthesia permit from the department of health (DOH); or

     (C) Providing conscious sedation with parenteral or multiple oral agents, deep sedation, or general anesthesia as a dentist, when the dentist has a conscious sedation permit or general anesthesia permit from DOH.

     (v) Practice medicine and osteopathy for:

     (A) Oral surgery procedures; or

     (B) Providing fluoride varnish under EPSDT.

     (b) Facilities that are:

     (i) Hospitals currently licensed by the department of health;

     (ii) Federally-qualified health centers (FQHCs);

     (iii) Medicare-certified ambulatory surgical centers (ASCs);

     (iv) Medicare-certified rural health clinics (RHCs); or

     (v) Community health centers.

     (c) Participating local health jurisdictions((; and)).

     (d) Border area or out-of-state providers of dental-related services who are qualified in their states to provide these services.

     (2) Subject to the restrictions and limitations in this section and other applicable WAC, MAA pays licensed providers participating in the MAA dental program for only those services that are within their scope of practice.

     (3) See WAC 388-502-0020 for provider documentation and record retention requirements. MAA ((may require)) requires additional dental documentation under specific sections in this chapter and as required by chapter 246-817 WAC.

     (4) See WAC 388-502-0100 and 388-502-0150 for provider billing and payment requirements.

     (5) See WAC 388-502-0160 for regulations concerning charges billed to clients.

     (6) See WAC 388-502-0230 for provider review and appeal.

     (7) See WAC 388-502-0240 for provider audits and the audit appeal process.

[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, § 388-535-1070, filed 6/14/02, effective 7/15/02.]

     (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 ((evaluations)) 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 ((evaluations)) 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 follows:

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

     (ii) Bitewings ((-)), total of four allowed every twelve months; and

     (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 ((X 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):

     (i) ((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

     (B) Xerostomia)).

     (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:

     (i) ((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 section.

     (g) Space mountaineers, for children through age eighteen only, as follows:

     (i) Fixed (unilateral type), one per quadrant;

     (ii) Fixed (bilateral type), one per arch; and

     (iii) Recommendation of space maintained, 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 multi surface restoration, and are reimbursed as such; and

     (ii) Proximal restorations that do not involve the incisa 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:

     (i) ((For clients age nineteen and older only.)) See subsection (3) of this section for clients of the division of developmental disabilities;

     (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 gingivoplasty.

     (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, but not both ((-)), allowed three times per calendar year;

     (b) Periodontal scaling and root planing ((-)), allowed once every six months;

     (c) Prophylaxis ((-)), allowed three times per calendar year;

     (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.]

     Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 02-13-074, filed 6/14/02, effective 7/15/02)

WAC 388-535-1100   Dental-related services not covered -- Children.   (1) The medical assistance administration (MAA) does not cover children's dental-related services described in subsection (2) of this section unless the services are:

     (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((; or

     (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) ((for adults)) for clients age eighteen through twenty, unless the clients are:

     (i) Clients of the division of developmental disabilities; or

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

     (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

     (B) Xerostomia)).

     (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;

     (h) Bridges;

     (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

     (4) ((Routine fluoride treatment (gel or varnish) for adults age nineteen through sixty-four who are diagnosed with xerostomia; and

     (5))) Selected procedures identified by the medical assistance administration (MAA) and published in its current dental billing instructions((, which are available from MAA in Olympia, Washington)).

[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;

     (b) ((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 anterior (((upper and lower) teeth)) 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 ((substate)) substrate;

     (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;

     (f) Impressions;

     (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.]

     (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.]

     (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) Limited visual oral assessment.

     (f) 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.

     (g) 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.

     (h) 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.

     (i) Restoration of teeth and maintenance of dental health:

     (i) Subject to the limitations in WAC 388-535-1265.

     (ii) Amalgam and composite restorations are allowed once in a two year period 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 with a cavity preparation for a carious lesion that penetrates through the enamel:

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

     (II) 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.

     (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 (see subsection (3) of this section).

     (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.

[]

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

     (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 (see WAC 388-535-1255(3));

     (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) Nitrous oxide, except as provided in WAC 388-535-1255(3) for clients of the division of developmental disabilities.

     (i) Behavior management, except as provided in WAC 388-535-1255(3) for clients of the division of developmental disabilities.

     (j) Occlusal adjustments.

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

     (l) Bridges, including abutment teeth and pontics.

     (m) Root canal services for primary teeth.

     (n) 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.

     (o) Pulpotomy services for permanent teeth.

     (p) Transitional dentures.

     (q) Overdentures.

     (r) Replacements for:

     (i) Immediate maxillary or mandibular dentures;

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

     (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.

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

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

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

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

     (w) Crown lengthening procedures.

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

     (y) Any treatment of TMJ/TMD.

     (z) 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.

     (aa) Alveoloplasty, alveoloectomy or tori/exostosis removal.

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

     (cc) 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.

     (dd) 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).

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

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

     (gg) Educational supplies.

     (hh) Missed or canceled appointments.

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

     (jj) Provider mileage or travel costs.

     (kk) Service charges or delinquent payment fees.

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

     (mm) Take-home drugs.

     (nn) Teeth whitening.

[]

     (1) Nonemergent inpatient hospital dental admissions as described under WAC 388-535-1100 (2)(o) and 388-550-1100(1);

     (2) Dentures and partial dentures as described in WAC 388-550-1290;

     (3) Fluoride treatment (gel or varnish) for clients age nineteen through sixty-four who are diagnosed with xerostomia; and

     (4) Selected procedures identified by the medical assistance administration (MAA) and published in its current dental billing instructions.

     (5) See WAC 388-535-1280 for obtaining prior authorization for dental-related services for adults.

[]

     (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) The client's patient identification code (PIC);

     (b) The client's name and address;

     (c) The provider's name and address;

     (d) The provider's telephone and fax number (including area code);

     (e) The provider's MAA-assigned seven-digit provider number;

     (f) The physiological description of the disease, injury, impairment, or other ailment;

     (g) The most recent and relevant radiographs that are identified with client name, provider name, and date the radiograph was taken;

     (h) The treatment plan;

     (i) Periodontal charting and diagnosis;

     (j) Study model, if requested; and

     (k) Photographs, if requested.

     (2) MAA considers requests for services according to WAC 388-535-1270.

     (3) MAA denies a request for dental services when the requested service is:

     (a) Not listed in chapter 388-535 WAC as a covered service;

     (b) Not medically necessary;

     (c) A service, procedure, treatment, device, drug, or application of associated service that the department or the Centers for Medicare and Medicaid Services (CMS) consider investigative or experimental on the date the service is provided; or

     (d) Covered under another department program or by an agency outside the department.

     (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.

[]

     (2) Subject to the criteria in this section and other applicable WAC, MAA covers the following for eligible adults:

     (a) Dentures, subject to the following limitations:

     (i) Only one complete maxillary denture and one complete mandibular denture allowed per client in a ten-year period, when constructed after the client has been without teeth for a period of time; or

     (ii) Only one immediate maxillary denture and one immediate mandibular denture allowed per client, per lifetime, and only when constructed prior to the removal of the client's teeth.

     (b) Replacement dentures, subject to the following limitations:

     (i) Only one replacement of a complete maxillary denture and one replacement of a complete mandibular denture allowed per client in a ten-year period; and

     (ii) Allowed only when the applicable criteria in subsection (5) of this section are met.

     (c) Partial dentures, subject to the following limitations:

     (i) Only one maxillary partial denture (resin) and one mandibular partial denture (resin) to replace one, two, or three missing anterior teeth per arch, allowed per client in a ten-year period; or

     (ii) Only one maxillary partial denture (cast metal framework) and one mandibular partial denture (cast metal framework) allowed per client in a ten-year period to replace:

     (A) Any combination of at least six anterior and posterior missing teeth per arch, excluding wisdom teeth; or

     (B) At least four anterior missing teeth per arch.

     (d) Replacement partial dentures, subject to the following limitations:

     (i) Only one replacement of a maxillary partial denture (cast metal framework) and a mandibular partial denture (cast metal framework) allowed per client in a ten-year period; and

     (ii) Allowed only when the applicable criteria in subsection (5) of this section are met.

     (3) Dentures must be of an acceptable structure and quality to meet the standard of care.

     (4) MAA covers complete denture and partial denture relines only once in a five-year period.

     (5) In addition to the prior authorization requirement and other limitations in this section, all replacement dentures and partial dentures are allowed once in a ten-year period and must:

     (a) Replace a complete maxillary denture, a complete mandibular denture, a maxillary partial denture (cast metal framework) or a mandibular partial denture (cast metal framework) (see subsection (2) of this section);

     (b) Replace dentures or partial dentures that are damaged beyond repair or are no longer serviceable and are unable to be relined;

     (c) Replace dentures or partial dentures that a client has been able to wear successfully; and

     (d) Be medically necessary, as defined in WAC 388-500-0005.

     (6) For billing purposes, a provider must:

     (a) Use the delivery date as the service date for the dentures and partial dentures; and

     (b) Use the impression date as the service date for dentures and partial dentures only when:

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

     (ii) The client is not eligible at the time of delivery; or

     (iii) The client does not return to obtain the dentures or partial dentures.

     (7) A provider must retain in a client's record:

     (a) Written laboratory prescriptions;

     (b) Receipts for laboratory fees;

     (c) Charts of missing teeth for partial dentures; and

     (d) Documentation that justifies the placement or replacement of dentures or partial dentures.

     (8) MAA does not pay separately for laboratory and professional fees for dentures and partial dentures. 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.

     (9) MAA does not pay separately for relines that are done within six months of the seat date. These procedures are included in the reimbursement for the dentures and partial dentures.

[]

     (1) For covered dental-related services provided to eligible clients, MAA pays dentists and ((related)) other eligible providers on a fee-for-service or contractual basis, subject to the exceptions and restrictions listed under WAC 388-535-1100 and 388-535-1400.

     (2) MAA sets maximum allowable fees for dental services provided to children as follows:

     (a) MAA's historical reimbursement rates for various procedures are compared to usual and customary charges.

     (b) MAA consults with representatives of the provider community to identify program areas and concerns that need to be addressed.

     (c) MAA consults with dental experts and public health professionals to identify and prioritize dental services and procedures for their effectiveness in improving or promoting children's dental health.

     (d) Legislatively authorized vendor rate increases and/or earmarked appropriations for children's dental services are allocated to specific procedures based on the priorities identified in (c) of this subsection and considerations of access to services.

     (e) Larger percentage increases may be given to those procedures which have been identified as most effective in improving or promoting children's dental health.

     (f) Budget-neutral rate adjustments are made as appropriate based on the department's evaluation of utilization trends, effectiveness of interventions, and access issues.

     (3) MAA reimburses dental general anesthesia services for eligible clients on the basis of base anesthesia units plus time. Payment for dental general anesthesia is calculated as follows:

     (a) Dental procedures are assigned an anesthesia base unit of five;

     (b) Fifteen minutes constitute one unit of time. When a dental procedure requiring dental general anesthesia results in multiple time units and a remainder (less than fifteen minutes), the remainder or fraction is considered as one time unit;

     (c) Time units are added to the anesthesia base unit of five and multiplied by the anesthesia conversion factor;

     (d) The formula for determining payment for dental general anesthesia is: (5.0 base anesthesia units + time units) x conversion factor = payment.

     (4) When billing for anesthesia, the provider must show the actual beginning and ending times on the claim. Anesthesia time begins when the provider starts to physically prepare the client for the induction of anesthesia in the operating room area (or its equivalent), and ends when the provider is no longer in constant attendance (i.e., when the client can be safety placed under post-operative supervision).

     (5) MAA ((may pay anesthesiologists)) pays eligible providers listed in WAC 388-535-1070 for conscious sedation with parenteral and multiple oral agents, or for general ((dental)) anesthesia ((provided in dental offices. Only anesthesiologists specially contracted by the department are paid an additional fee for that service)) when the provider meets the criteria in this chapter and other applicable WAC.

     (6) Dental hygienists who have a contract with MAA are paid at the same rate as dentists who have a contract with MAA, for services allowed under The Dental Hygienist Practice Act((, which is available from the department of health, Olympia, Washington)).

     (7) Licensed denturists who have a contract with MAA are paid at the same rate as dentists who have a contract with MAA, for providing dentures and partials.

     (8) MAA makes fee schedule changes whenever the legislature authorizes vendor rate increases or decreases.

     (9) MAA may adjust maximum allowable fees to reflect changes in services or procedure code descriptions.

[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, § 388-535-1350, 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, § 388-535-1350, 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), § 388-535-1350, filed 12/6/95, effective 1/6/96.]

     Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 02-13-074, filed 6/14/02, effective 7/15/02)

WAC 388-535-1400   Payment for dental-related services.   (1) The medical assistance administration (MAA) considers that a provider who furnishes covered dental services to an eligible client has accepted MAA's rules and fees.

     (2) Participating providers must bill MAA their usual and customary fees.

     (3) Payment for dental services is based on MAA's schedule of maximum allowances. Fees listed in the MAA fee schedule are the maximum allowable fees.

     (4) MAA pays the provider the lesser of the billed charge (usual and customary fee) or MAA's maximum allowable fee.

     (5) MAA pays "by report" on a case-by-case basis, for a covered service that does not have a set fee.

     (6) Participating providers must bill a client according to WAC 388-502-0160, unless otherwise specified in this chapter.

     (7) If the client's eligibility for dental services ends before the conclusion of the dental treatment, payment for any remaining treatment is the client's responsibility. The exception to this is dentures and ((partials as stated)) partial dentures as described in WAC 388-535-1240 and 388-535-1290.

     (((7) The client is responsible for payment of any dental treatment or service received during any period of ineligibility with the exception described in WAC 388-535-1240(4) even if the treatment was started when the client was eligible.))

[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, § 388-535-1400, 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, § 388-535-1400, 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), § 388-535-1400, filed 12/6/95, effective 1/6/96.]

[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, § 388-535-1450, 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, § 388-535-1450, 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), § 388-535-1450, filed 12/6/95, effective 1/6/96.]

     The following section of the Washington Administrative Code is repealed:

WAC 388-535-1120

Coverage limits for dental-related services provided under state-only funded programs.

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