WSR 07-02-088

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed January 3, 2007, 8:43 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 05-21-093.

Title of Rule and Other Identifying Information: Part 1 of 4; amending WAC 388-535-1050 Dental-related definitions and 388-535-1065 Coverage limits for dental-related services provided under state-only funded programs; and new section WAC 388-535-1247 Dental-related services for clients age twenty-one and older--General.

Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane, behind Goodyear Tire. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on February 6, 2007, at 10:00 a.m.

Date of Intended Adoption: Not earlier than February 7, 2007.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail schilse@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m. on February 6, 2007.

Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by February 2, 2007, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The new and amended sections clarify and update policies for dental-related services for clients age twenty-one and older; ensure that department policies are applied correctly and equitably; replace the terms "medical assistance administration" and "MAA" with "the department"; update policy regarding prior authorization requirements; clarify policy on covered versus noncovered benefits; and clarify additional benefits and limitations associated with those services for clients age twenty-one and older.

Reasons Supporting Proposal: To clarify what new dental-related services are covered and the limitations associated with those services; to make HRSA's rules regarding covered and noncovered dental-related services for clients age twenty-one and older clearer and easier to understand for clients and dental providers; and to identify the requirements and criteria that must be met in order to obtain covered dental-related services.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.500, 74.09.520.

Statute Being Implemented: RCW 74.08.090, 74.09.500, 74.09.520.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of social and health services, governmental.

Name of Agency Personnel Responsible for Drafting: Kathy Sayre, 626 8th Avenue, Olympia, WA 98504-5504, (360) 725-1342; Implementation and Enforcement: Dr. John Davis, 626 8th Avenue, Olympia, WA 98504-5506, (360) 725-1748.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rules do not create more than minor costs to small businesses.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Dr. John Davis, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1748, TYY/TDD 1-800-848-5429, fax (360) 586-1590, e-mail davisjd@dshs.wa.gov.

December 27, 2006

Andy Fernando, Manager

Rules and Policies Assistance Unit

3822.2
AMENDATORY SECTION(Amending WSR 04-14-100, filed 7/6/04, effective 8/6/04)

WAC 388-535-1050   Dental-related definitions.   The following definitions and abbreviations and those found in WAC 388-500-0005 apply to this chapter. The ((medical assistance administration (MAA))) department also uses dental definitions found in the American Dental Association's Current Dental Terminology (CDT) and the American Medical Association's Physician's Current Procedural Terminology (CPT). Where there is any discrepancy between the CDT or CPT and this section, this section prevails. (CPT is a trademark of the American Medical Association.)

"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.

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

(("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).))

"Anterior" ((means teeth)) refers to teeth (maxillary and mandibular incisors and canines) and tissue in the front of the mouth. Permanent maxillary anterior teeth include teeth six, seven, eight, nine, ten, and eleven. Permanent mandibular anterior teeth include teeth twenty-two, twenty-three, twenty-four, twenty-five, twenty-six, and twenty-seven. Primary maxillary anterior teeth include teeth C, D, E, F, G, and H. Primary mandibular anterior teeth include teeth M, N, O, P, Q, and R.

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

"Asymptomatic" means having or producing no symptoms.

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

"Behavior management" means using the assistance of one additional dental professional staff to manage the behavior of ((a developmentally disabled client or)) a client ((age eighteen or younger)) to facilitate the delivery of dental treatment.

"By report" - a method of reimbursement in which ((MAA)) the department determines the amount it will pay for a service when the rate for that service is not included in ((MAA's)) the department'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 carious lesions or 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)) documentation of 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 tissue anomalies, and oral cancer screening.

"Conscious sedation" is a drug-induced depression of consciousness during which a client((s)) responds 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 maintained.

"Core buildup" refers to building up of clinical crowns, including pins.

"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 mechanical procedure limited to the removal of plaque and stain from exposed tooth surfaces.

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

"Current dental terminology (CDT)" is 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)" ((means a description of medical procedures and is available from the American Medical Association of Chicago, Illinois)) is a systematic listing of descriptive terms and identifying codes for reporting medical services, procedures, and interventions performed by physicians and other practitioners who provide physician-related services. CPT is copyrighted and published annually by the American Medical Association (AMA).

"Decay" is a term for caries or carious lesions and means decomposition of tooth structure.

"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" see "general anesthesia."

"Dentures" means an artificial replacement for natural teeth and adjacent tissues, and includes complete dentures, immediate dentures, overdentures, and partial dentures.

"Denturist" means a person licensed under chapter 18.30 RCW to make, construct, alter, reproduce, or repair a denture.

"Endodontic" means ((disease and injuries to the pulp requiring root canal therapy and related follow-up)) the etiology, diagnosis, prevention and treatment of diseases and injuries of the pulp and associated periradicular conditions.

"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 ((low viscosity resin)) diluted resin-based composite dental restorative material that is used in cervical ((lesions)) restorations and ((other)) small, low stress bearing occlusal restorations.

"Fluoride varnish, rinse, foam or gel" ((means)) is a substance containing dental fluoride((,)) which is applied to teeth.

"General anesthesia" is a drug-induced loss of consciousness during which a client((s are)) is 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 noble metal" ((means)) is a dental alloy containing at least sixty percent pure gold.

"Limited oral evaluation" ((means)) is 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)) is an assessment by a dentist or dental hygienist to determine the need for fluoride treatment and/or when triage services are provided in settings other than dental offices or dental clinics.

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

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

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

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

"Oral evaluation" see "comprehensive oral evaluation."

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

"Oral prophylaxis" ((means)) is the ((preventive)) dental procedure of scaling and polishing which includes removal of calculus, ((soft deposits,)) plaque, and stains from teeth ((and tooth implants)).

"Partials" or "partial dentures" ((means)) are a removable prosthetic appliance ((replacing one or more)) that replaces missing teeth in one arch((, and receiving its support and retention from both the underlying tissues and some or all of the remaining teeth)).

"Periodic oral evaluation" ((means)) is 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)) is 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 from teeth and tooth implants)) performed for clients who have previously been treated for periodontal disease with surgical or nonsurgical treatment. It includes the removal of supragingival and subgingival microorganisms and deposits with hand and mechanical instrumentation, an evaluation of periodontal conditions, and a complete periodontal charting as appropriate.

"Periodontal scaling and root planing" ((means instrumentation of the crown and root surfaces of the teeth or tooth implants)) is a procedure to remove plaque, calculus, ((microbial flora, and bacterial toxins)) microorganisms, and rough cementum and dentin from tooth surfaces. This includes hand and mechanical instrumentation, an evaluation of periodontal conditions, and a complete periodontal charting as appropriate.

"Posterior" ((means)) refers to the teeth (maxillary and mandibular premolars and molars) and tissue towards the back of the mouth. Permanent maxillary posterior teeth include teeth one, two, three, four, five, twelve, thirteen, fourteen, fifteen, and sixteen. Permanent mandibular posterior teeth include teeth seventeen, eighteen, nineteen, twenty, twenty-one, twenty-eight, twenty-nine, thirty, thirty-one, and thirty-two. Primary maxillary posterior teeth include teeth A, B, I, and J. Primary mandibular posterior teeth include teeth K, L, S, and T.

(((1) "Mandibular posterior teeth" - 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)) is the surface of the tooth near or next to the adjacent tooth.

"Radiograph" is an image or picture produced on a radiation sensitive film emulsion or digital sensor by exposure to ionizing radiation.

"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 a procedure to remove ((microbial flora, bacterial toxins)) plaque, calculus, ((and diseased)) microorganisms, and rough cementum ((or dentin on the root)) and dentin from tooth surfaces ((and pockets, including tooth implants)). This includes hand and mechanical instrumentation.

"Scaling" is a procedure to remove plaque, calculus, and stain deposits from tooth surfaces((, including tooth implants)).

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

"Simple extraction" ((means)) is the routine removal of a tooth ((structure)).

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

"Surgical extraction" ((means)) is the removal of a tooth ((structure with)) by cutting of the gingiva and bone((, including)). This includes soft tissue extractions, partial boney extractions, and complete boney extractions.

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

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

"Therapeutic pulpotomy" ((means)) is 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)) the department.

"Wisdom teeth" ((means)) are the third molars, teeth one, sixteen, seventeen, and thirty-two.

"Xerostomia" ((means)) is a dryness of the mouth due to decreased saliva.

[Statutory Authority: RCW 74.04.050, 74.04.057, and 74.09.530. 04-14-100, 388-535-1050, filed 7/6/04, effective 8/6/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-077, 388-535-1050, filed 9/12/03, effective 10/13/03. 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 spelling errors in the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 04-14-100, filed 7/6/04, effective 8/6/04)

WAC 388-535-1065   Coverage limits for dental-related services provided under ((state-only funded)) the GA-U and ADATSA programs.   (1) Clients who receive medical care services under the following ((state-funded only)) programs may receive ((only the limited coverage)) the dental-related services described in ((subsection (2) of)) this section:

(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))) department covers the following dental-related services ((described and limited in this chapter)) for a client((s)) eligible ((for)) under the GA-U or ((GA-W only when those services are provided as part of a medical treatment for)) ADATSA program:

(a) ((Apical abscess verified by clinical examination and radiograph(s), and treated by)) Services provided only as part of dental treatment for:

(i) Limited oral evaluation;

(ii) Periapical or bite-wing radiographs that are medically necessary to diagnose only the client's chief complaint;

(iii) Palliative treatment (((e.g., open and drain, open and broach))) to relieve dental pain;

(((ii) Tooth extraction; or

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

(b) Tooth fractures (limited to extraction).

(c) Total dental extraction prior to and because of radiation therapy for cancer of the mouth))

(iv) Pulpal debridement to relieve dental pain; or

(v) Endodontic (root canal only) treatment for maxillary and mandibular anterior teeth (cuspids and incisors) when prior authorized).

(b) Tooth extraction when at least one of the following apply:

(i) The tooth has a radiograph apical lesion;

(ii) The tooth is endodontically involved, infected, or abcessed;

(iii) The tooth is not restorable; or

(iv) The tooth is not periodontally stable.

(3) Tooth extractions require prior authorization when:

(i) The extraction of a tooth or teeth results in the client becoming edentulous in the maxillary arch or mandibular arch; and

(ii) A full mouth extraction is necessary because of radiation therapy for cancer of the head and neck.

(4) Each dental-related procedure described under this section is subject to the coverage limitations listed in chapter 388-535 WAC for clients through age twenty.

(5) The department does not cover any dental-related services not listed in this section for clients eligible under the GA-U or ADATSA program, including any type of removable prosthesis (denture).

[Statutory Authority: RCW 74.04.050, 74.04.057, and 74.09.530. 04-14-100, 388-535-1065, filed 7/6/04, effective 8/6/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-077, 388-535-1065, filed 9/12/03, effective 10/13/03.]


NEW SECTION
WAC 388-535-1247   Dental-related services for clients age twenty-one and older-General.   (1) The department pays for dental-related services and procedures provided to clients age twenty-one and older when the services and procedures:

(a) Are within the scope of an eligible client's medical care program;

(b) Are medically necessary as defined in WAC 388-500-0005;

(c) Meet the department's prior authorization requirements, if any;

(d) Are within accepted dental or medical practice standards;

(e) Are consistent with a diagnosis of dental disease or condition;

(f) Are reasonable in amount and duration of care, treatment, or service; and

(g) Are listed as covered in the department's published rules, billing instructions and fee schedules.

(2) Clients who are eligible for services through the division of developmental disabilities may receive dental-related services under the provisions of WAC 388-535-1099.

(3) The department evaluates a request for dental-related services:

(a) That are in excess of the dental program's limitations or restrictions, according to WAC 388-501-0169; and

(b) That are listed as noncovered under the provisions in WAC 388-501-0160.

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Washington State Code Reviser's Office