PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 05-21-093.
Title of Rule and Other Identifying Information: Part 2 of 4; amending WAC 388-535-1255 Covered dental-related services -- Adults; and new sections WAC 388-535-1257 Covered dental-related services for clients age twenty-one and older--Preventive services, 388-535-1259 Covered dental-related services for clients age twenty-one and older--Restorative services, and 388-535-1261 Covered dental-related services for clients age twenty-one and older--Endodontic services.
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
3824.2(a) Within the scope of an eligible client's medical care program;
(b) Medically necessary; and
(c) Within accepted dental or medical practice standards and are:
(i) Consistent with a diagnosis of dental disease or condition; and
(ii) Reasonable in amount and duration of care, treatment, or service.
(2) MAA covers the following dental-related services for eligible 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 prescheduled dental services for the client. The limited oral evaluation must be:
(i) To provide limited or emergent services for a specific dental problem; and/or
(ii) To provide an evaluation for a referral.
(e) Radiographs, as follows:
(i) Intraoral, complete series (including bitewings), allowed only once in a three-year period;
(ii) Panoramic film, allowed only once in a three-year period and only for oral surgical purposes (see subsection (3) of this section for clients of the division of developmental disabilities);
(iii) Periapical radiographs as needed (periapical radiographs and bitewings taken on the same date of service cannot exceed MAA's fee for a complete intraoral series); and
(iv) Bitewings, up to four allowed every twelve months.
(f) Fluoride treatment as follows (see subsection (3) of this section for clients of the division of developmental disabilities):
(i) Topical application of fluoride gel or fluoride varnish for adults age nineteen through sixty-four with xerostomia (requires prior authorization); and
(ii) Topical application of fluoride gel or fluoride varnish for adults age sixty-five and older for:
(A) Rampant root surface decay; or
(B) Xerostomia.
(g) Oral prophylaxis treatment, which is:
(i) Allowed once every twelve months for adults age nineteen and older, including nursing facility clients, and for clients of the division of developmental disabilities as provided in subsection (3) of this section;
(ii) Not reimbursed when oral prophylaxis treatment is performed on the same date of service as periodontal scaling and root planing, gingivectomy, or gingivoplasty; and
(iii) Reimbursed only if periodontal maintenance is not billed for the same client within the same twelve-month period.
(h) Restoration of teeth and maintenance of dental health, subject to the limitations in WAC 388-535-1265 and the following:
(i) Amalgam and composite restorations are allowed once for the same surface of the same tooth per client, per provider;
(ii) 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.
(iii) 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.
(iv) 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.
(v) 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.
(vi) 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.
(vii) MAA pays for a core buildup on an anterior or a posterior tooth, including any pins, which is allowed once per client, per provider, in a two-year period, subject to the following:
(A) MAA does not pay for a core buildup when a permanent or temporary crown is being placed on the same tooth.
(B) MAA does not pay for a core buildup when placed in combination with any other restoration on the same tooth.
(viii) MAA pays for flowable composites as a restoration only, when used with a cavity preparation for a carious lesion that penetrates through the enamel:
(A) As a small Class I (occlusal) restoration; or
(B) As a Class V (buccal or lingual) restoration.
(i) Endodontic (root canal) therapy for permanent anterior teeth only.
(j) 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. Refer to subsection (2)(g) of this section for limitations on oral prophylaxis. Refer to subsection (2)(k) of this section for limitations on periodontal maintenance.
(k) 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 twelve months after completion of periodontal scaling and root planing or surgical treatment and paid only at twelve month intervals;
(vii) Not reimbursed when the periodontal maintenance is performed on the same date of service as periodontal scaling and root planing, gingivectomy, or gingivoplasty; and
(viii) Reimbursed only if oral prophylaxis is not billed for the same client within the same twelve-month period.
(l) Dentures and partial dentures according to WAC 388-535-1290.
(m) Simple extractions (includes local anesthesia, suturing, and routine postoperative care).
(n) 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.
(o) Medically necessary oral surgery when coordinated with the client's managed care plan (if any).
(p) Palliative (emergency) treatment of dental pain and infections, minor procedures, which is:
(i) Allowed once per client, per day.
(ii) Reimbursed 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) Reimbursed only when a description of the service is included in the client's record.
(q) Behavior management that requires the assistance of one additional dental professional staff for clients of the division of developmental disabilities. See subsection (3) of this section.
(3) For clients of the division of developmental disabilities, MAA allows services as follows:
(a) Fluoride application, either varnish or gel, three times per calendar year;
(b) One of the following combinations of preventive or periodontal procedures, subject to the limitations listed:
(i) Prophylaxis or periodontal maintenance, three times per calendar year;
(ii) Periodontal scaling and root planing, two times per calendar year; or
(iii) Prophylaxis or periodontal maintenance, two times per calendar year, and periodontal scaling and root planing, once per calendar year.
(c) Gingivectomy or gingivectoplasty, allowed for four or more contiguous teeth or bounded teeth spaces per quadrant, once every three years.
(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;
(g) General anesthesia or conscious sedation with parenteral or multiple oral agents when medically necessary for providing treatment; and
(h) Limited visual oral assessment (does not replace an oral evaluation) when the assessment includes appropriate referrals, charting of patient data and oral health status and informing the client's parent or guardian of the results, and when at least one of the following occurs:
(i) The provision of triage services;
(ii) An intraoral screening of soft tissues by a public health dental hygienist to assess the need for prophylaxis, fluoride varnish, or referral for other dental treatments by a dentist; or
(iii) In circumstances where the client will be referred to a dentist for treatment, the referring provider will not provide treatment or provide a full evaluation at the time of the assessment.
(4) MAA covers dental services that are medically necessary and provided in a hospital under the direction of a physician or dentist for:
(a) The care or treatment of teeth, jaws, or structures directly supporting the teeth if the procedure requires hospitalization;
(b) Short stays when the procedure cannot be done in an office setting. See WAC 388-550-1100(6); and
(c) A hospital call, including emergency care, allowed one per day, per client, per provider.
(5) MAA covers general anesthesia and conscious sedation with parenteral or multiple oral agents for medically necessary dental services as follows:
(a) For treatment of clients who are eligible under the division of developmental disabilities.
(b) For oral surgery procedures.
(c) When justification for administering the general anesthesia instead of a lesser type of sedation is clearly documented in the client's record.
(d) When the anesthesia is administered by:
(i) An oral surgeon who has a current conscious sedation permit or a current general anesthesia permit from DOH;
(ii) An anesthesiologist;
(iii) A dental anesthesiologist who has a current conscious sedation permit or a current general anesthesia permit from DOH;
(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, as appropriate, allowed once per day (not per client and not per facility), per provider; and
(b) Nursing facilities must provide dental-related necessary services according to WAC 388-97-012, Nursing facility care)) The department covers dental-related diagnostic services only as listed in this section for clients age twenty-one and older (for dental-related services provided to clients eligible under the GA-U or ADATSA program, see WAC 388-535-1065).
(1) Clinical oral evaluations. The department covers:
(a) Oral health evaluations and assessments. The services must be documented in the client's record in accordance with WAC 388-502-0020;
(b) Periodic oral evaluations as defined in WAC 388-535-1050, once every twelve months. Twelve months must elapse between the comprehensive oral evaluation and the first periodic oral evaluation;
(c) Limited oral evaluations as defined in WAC 388-535-1050, only when the provider performing the limited oral evaluation is not providing routine scheduled dental services for the client. The limited oral evaluation:
(i) Must be to evaluate the client for a:
(A) Specific dental problem or oral health complaint;
(B) Dental emergency; or
(C) Referral for other treatment.
(ii) When performed by a denturist, is limited to the initial examination appointment. The department does not cover an additional limited oral examination by a denturist for the same client until three months after the removable prosthesis has been seated.
(d) Comprehensive oral evaluations as defined in WAC 388-535-1050, once per client, per provider or clinic, as an initial examination. The department covers an additional comprehensive oral evaluation if the client has not been treated by the same provider or clinic within the past five years;
(e) Limited visual oral assessments as defined in WAC 388-535-1050, up to two per client, per year, per provider only when the assessment is:
(i) Not performed in conjunction with other clinical evaluation services;
(ii) Performed to determine the need for fluoride treatment and/or when triage services are provided in settings other than dental offices or clinics; and
(iii) Provided by a licensed dentist or licensed dental hygienist.
(2) Radiographs (X-rays). The department:
(a) Covers radiographs that are of diagnostic quality, dated, and labeled with the client's name. The department requires original radiographs to be retained by the provider as part of the client's dental record, and duplicate radiographs to be submitted with prior authorization requests or when copies of dental records are required.
(b) Uses the prevailing standard of care to determine the need for dental radiographs.
(c) Covers intraoral complete series (includes four bitewings), once in a three-year period only if the department has not paid for a panoramic radiograph for the same client in the same three-year period.
(d) Covers periapical radiographs that are not included in a complete series. Documentation supporting the medical necessity for these must be in the client's record.
(e) Covers up to four bitewing radiographs once in a twelve month period.
(f) Covers panoramic radiographs in conjunction with four bitewings, once in a three-year period, only if the department has not paid for an intraoral complete series for the same client in the same three-year period.
(g) May cover panoramic radiographs for preoperative or postoperative surgery cases more than once in a three-year period, only on a case-by-case basis and when prior authorized.
[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. 03-19-079, § 388-535-1255, filed 9/12/03, effective 10/13/03.]
(1) Dental prophylaxis. The department covers dental prophylaxis:
(a) Which includes scaling and polishing procedures to remove coronal plaque, calculus, and stains once every twelve months;
(b) Only when the service is performed twelve months after periodontal scaling and root planing, or periodontal maintenance services;
(c) Only when not performed on the same date of service as periodontal scaling and root planing, or periodontal maintenance, gingivectomy or gingivoplasty; and
(d) For clients of the division of development disabilities according to WAC 388-535-1099.
(2) Topical fluoride treatment. The department covers:
(a) Fluoride rinse, foam or gel, once within a twelve month period;
(b) Fluoride varnish, rinse, foam or gel for clients who are age sixty-five and older, or clients who reside in alternative living facilities, up to three times within a twelve-month period;
(c) Additional topical fluoride applications when prior authorized; and
(d) Topical fluoride treatment for clients of the division of developmental disabilities according to WAC 388-535-1099.
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(1) Amalgam restorations for permanent teeth. The department:
(a) Considers tooth preparation, all adhesives (including amalgam bonding agents), liners, bases, and polishing as part of the amalgam restoration;
(b) Considers the occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of the restoration;
(c) Considers buccal or lingual surface amalgam restorations, regardless of size or extension, as a one surface restoration. The department covers only one buccal and one lingual surface per tooth;
(d) Considers multiple amalgam restorations of fissures and grooves of the occlusal surface of the same tooth as a one surface restoration;
(e) Covers two occlusal amalgam restorations for teeth one, two, three, fourteen, fifteen, and sixteen, if the restorations are anatomically separated by sound tooth structure;
(f) Covers amalgam restorations for a maximum of five surfaces per tooth for a permanent posterior tooth, once per client, per provider or clinic, in a two-year period;
(g) Covers amalgam restorations for a maximum of six surfaces per tooth for teeth one, two, three, fourteen, fifteen and sixteen, once per client, per provider or clinic, in a two-year period. See also (e) of this subsection; and
(h) Does not pay for replacement of an amalgam restoration by the same provider on a permanent posterior tooth within a two-year period unless the restoration has an additional adjoining carious surface. The department pays for the replacement restoration as one multi-surface restoration. The client's record must include radiographs and documentation supporting the medical necessity for the replacement restoration.
(2) Resin-based composite restorations for permanent teeth. The department:
(a) Considers tooth preparation, acid etching, all adhesives (including resin bonding agents), liners and bases, polishing, and curing as part of the resin-based composite restoration;
(b) Considers the occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of the resin-based composite restoration;
(c) Considers buccal or lingual surface resin-based composite restorations, regardless of size or extension, as a one surface restoration. The department covers only one buccal and one lingual surface per tooth;
(d) Considers resin-based composite restorations of teeth where the decay does not penetrate the DEJ to be sealants. The department does not cover sealants for clients age twenty-one and older;
(e) Considers multiple preventive restorative resins or flowable composite resins for the occlusal, buccal, lingual, mesial, and distal fissures and grooves on the same tooth as a one surface restoration;
(f) Does not cover preventive restorative resin or flowable composite resin on the interproximal surfaces (mesial and/or distal) of posterior teeth or the incisal surface of anterior teeth;
(g) Covers two occlusal resin-based composite restorations for teeth one, two, three, fourteen, fifteen, and sixteen if the restorations are anatomically separated by sound tooth structure;
(h) Covers resin-based composite restorations for a maximum of five surfaces per tooth for a permanent posterior tooth, once per client, per provider or clinic, in a two-year period;
(i) Covers resin-based composite restorations for a maximum of six surfaces per tooth for permanent posterior teeth one, two, three, fourteen, fifteen and sixteen, once per client, per provider or clinic, in a two-year period. See also (g) of this subsection;
(j) Covers resin-based composite restorations for a maximum of six surfaces per tooth for a permanent anterior tooth, once per client, per provider or clinic, in a two-year period; and
(k) Does not pay for replacement of resin-based composite restorations by the same provider on permanent teeth within a two-year period unless the restoration has an additional adjoining carious surface. The department pays for the replacement restoration as one multi-surface restoration. The client's record must include radiographs and documentation supporting the medical necessity for the replacement restoration.
(3) Crowns. The department:
(a) Does not cover permanent crowns for clients age twenty-one and older, except for prefabricated stainless steel crowns for posterior permanent teeth on a case-by-case basis when prior authorized; and
(b) Covers crowns for clients of the division of developmental disabilities according to WAC 388-535-1099.
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(1) Pulpal debridement. The department covers pulpal debridement on permanent teeth. Pulpal debridement is not covered when performed with palliative treatment or when performed on the same day as endodontic treatment.
(2) Endodontic treatment. The department:
(a) Covers endodontic treatment for permanent anterior teeth only;
(b) Considers the following included in endodontic treatment:
(i) Pulpectomy when part of root canal therapy;
(ii) All procedures necessary to complete treatment; and
(iii) All intra-operative and final evaluation radiographs for the endodontic procedure.
(c) Pays separately for the following services that are related to the endodontic treatment:
(i) Initial diagnostic evaluation;
(ii) Initial diagnostic radiographs; and
(iii) Post treatment evaluation radiographs if taken at least three months after treatment.
(d) Requires prior authorization for endodontic retreatment and considers endodontic retreatment to include:
(i) The removal of post(s), pin(s), old root canal filling material, and all procedures necessary to prepare the canals;
(ii) Placement of new filling material; and
(iii) Retreatment for permanent maxillary and mandibular anterior teeth only.
(e) Pays separately for the following services that are related to the endodontic retreatment:
(i) Initial diagnostic evaluation;
(ii) Initial diagnostic radiographs; and
(iii) Post treatment evaluation radiographs if taken at least three months after treatment.
(f) Does not pay for endodontic retreatment when provided by the original treating provider or clinic.
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