WSR 07-02-091

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed January 3, 2007, 8:46 a.m. ]

Original Notice.

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

Title of Rule and Other Identifying Information: Part 4 of 4; new section WAC 388-535-1271 Dental-related services not covered for clients age twenty-one and older; amending WAC 388-535-1280 Obtaining prior authorization for dental-related services--Adults; and repealing WAC 388-535-1270 Dental-related services requiring prior authorization and 388-535-1290 Dentures and partial dentures for adults.

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

3826.2
NEW SECTION
WAC 388-535-1271   Dental-related services not covered for clients age twenty-one and older.   (1) The department does not cover the following for clients age twenty-one and older (see WAC 388-535-1065 for dental-related services for clients eligible under the GA-U or ADATSA program):

(a) The dental-related services and procedures described in subsection (2) of this section;

(b) Any service specifically excluded by statute;

(c) More costly services when less costly, equally effective services as determined by the department are available; and

(d) Services, procedures, treatment, devices, drugs, or application of associated services:

(i) Which the department or the Centers for Medicare and Medicaid Services (CMS) considers investigative or experimental on the date the services were provided.

(ii) That are not listed as covered in one or both of the following:

(A) Washington Administrative Code (WAC).

(B) The department's published documents (e.g., billing instructions).

(2) The department does not cover dental-related services listed under the following categories of service for clients age twenty-one and older:

(a) Diagnostic services. The department does not cover:

(i) Detailed and extensive oral evaluations or re-evaluations;

(ii) Comprehensive periodontal evaluations;

(iii) Extraoral or occlusal intraoral radiographs;

(iv) Posterior-anterior or lateral skull and facial bone survey films;

(v) Sialography;

(vi) Any temporomandibular joint films;

(vii) Tomographic survey;

(viii) Cephalometric films;

(ix) Oral/facial photographic images;

(x) Viral cultures, genetic testing, caries susceptibility tests, adjunctive pre-diagnostic tests, or pulp vitality tests; or

(xi) Diagnostic casts.

(b) Preventive services. The department does not cover:

(i) Nutritional counseling for control of dental disease;

(ii) Tobacco counseling for the control and prevention of oral disease;

(iii) Oral hygiene instructions (included as part of the global fee for oral prophylaxis);

(iv) Removable space maintainers of any type;

(v) Sealants;

(vi) Space maintainers of any type or recementation of space maintainers; or

(vii) Fluoride trays of any type.

(c) Restorative services. The department does not cover:

(i) Restorative/operative procedures performed in a hospital operating room or ambulatory surgical center for clients age twenty-one and older. For clients of the division of developmental disabilities, see WAC 388-535-1099;

(ii) Gold foil restorations;

(iii) Metallic, resin-based composite, or porcelain/ceramic inlay/onlay restorations;

(iv) Prefabricated resin crowns;

(v) Temporary or provisional crowns (including ion crowns);

(vi) Any type of permanent or temporary crown. For clients of the division of developmental disabilities see WAC 388-535-1099;

(vii) Recementation of any crown, inlay/onlay, or any other type of indirect restoration;

(viii) Sedative fillings;

(ix) Preventive restorative resins;

(x) Any type of core buildup, cast post and core, or prefabricated post and core;

(xi) Labial veneer resin or porcelain laminate restoration;

(xii) Any type of coping;

(xiii) Crown repairs; or

(xix) Polishing or recontouring restorations or overhang removal for any type of restoration.

(d) Endodontic services. The department does not cover:

(i) Indirect or direct pulp caps;

(ii) Endodontic therapy on any primary teeth for clients age twenty-one and older;

(iii) Endodontic therapy on permanent bicuspids or molar teeth;

(iv) Any apexification/recalcification procedures;

(v) Any apicoectomy/periradicular service; or

(vi) Any surgical endodontic procedures including, but not limited to, retrograde fillings, root amputation, reimplantation, and hemisections.

(e) Periodontic services. The department does not cover:

(i) Surgical periodontal services that include, but are not limited to:

(A) Gingival or apical flap procedures;

(B) Clinical crown lengthening;

(C) Any type of osseous surgery;

(D) Bone or soft tissue grafts;

(E) Biological material to aid in soft and osseous tissue regeneration;

(F) Guided tissue regeneration;

(G) Pedicle, free soft tissue, apical positioning, subepithelial connective tissue, soft tissue allograft, combined connective tissue and double pedicle, or any other soft tissue or osseous grafts; or

(H) Distal or proximal wedge procedures; or

(ii) Nonsurgical periodontal services, including but not limited to:

(A) Intracoronal or extracoronal provisional splinting;

(B) Full mouth debridement;

(C) Localized delivery of chemotherapeutic agents; or

(D) Any other type of nonsurgical periodontal service.

(f) Prosthodontics (removable). The department does not cover any type of:

(i) Removable unilateral partial dentures;

(ii) Adjustments to any removable prosthesis;

(iii) Chairside complete or partial denture relines;

(iv) Any interim complete or partial denture;

(v) Precision attachments; or

(vi) Replacement of replaceable parts for semi-precision or precision attachments.

(g) Oral and maxillofacial prosthetic services. The department does not cover any type of oral or facial prosthesis other than those listed in WAC 388-535-1265.

(h) Implant services. The department does not cover:

(i) Any implant procedures, including, but not limited to, any tooth implant abutment (e.g., periosteal implant, eposteal implant, and transosteal implant), abutments or implant supported crown, abutment supported retainer, and implant supported retainer;

(ii) Any maintenance or repairs to procedures listed in (h)(i) of this subsection; or

(iii) The removal of any implant as described in (h)(i) of this subsection.

(i) Prosthodontics (fixed). The department does not cover any type of:

(i) Fixed partial denture pontic;

(ii) Fixed partial denture retainer;

(iii) Precision attachment, stress breaker, connector bar, coping, or cast post; or

(iv) Other fixed attachment or prosthesis.

(j) Oral and maxillofacial surgery. The department does not cover:

(i) Any nonemergency oral surgery performed in a hospital or ambulatory surgical center for Current Dental Terminology (CDT) procedures;

(ii) Vestibuloplasty;

(iii) Frenuloplasty/frenulectomy;

(iv) Any oral surgery service not listed in WAC 388-535-1267;

(v) Any oral surgery service that is not listed in the department's list of covered Current Procedural Terminology (CPT) codes published in the department's current rules or billing instructions;

(vi) Any type of occlusal orthotic splint or device, bruxing or grinding splint or device, temporomandibular joint splint or device, or sleep apnea splint or device; or

(vii) Any type of orthodontic service or appliance.

(k) Adjunctive general services. The department does not cover:

(i) Anesthesia to include:

(A) Local anesthesia as a separate procedure;

(B) Regional block anesthesia as a separate procedure;

(C) Trigeminal division block anesthesia as a separate procedure;

(D) Analgesia or anxiolysis as a separate procedure except for inhalation of nitrous oxide;

(E) Medication for oral sedation, or therapeutic drug injections, including antibiotic or injection of sedative; or

(F) Application of any type of desensitizing medicament or resin.

(ii) Other general services including, but not limited to:

(A) Fabrication of athletic mouthguard, occlusal guard, or nightguard;

(B) Occlusion analysis;

(C) Occlusal adjustment or odontoplasties;

(D) Enamel microabrasion;

(E) Dental supplies, including but not limited to, toothbrushes, toothpaste, floss, and other take home items;

(F) Dentist's or dental hygienist's time writing or calling in prescriptions;

(G) Dentist's or dental hygienist's time consulting with clients on the phone;

(H) Educational supplies;

(I) Nonmedical equipment or supplies;

(J) Personal comfort items or services;

(K) Provider mileage or travel costs;

(L) Missed or late appointment fees;

(M) Service charges of any type, including fees to create or copy charts;

(N) Office supplies used in conjunction with an office visit; or

(O) Teeth whitening services or bleaching, or materials used in whitening or bleaching.

[]


AMENDATORY SECTION(Amending WSR 03-19-080, filed 9/12/03, effective 10/13/03)

WAC 388-535-1280   Obtaining prior authorization for dental-related services(( -- Adults)) for clients age twenty-one and older.   ((When the medical assistance administration (MAA) authorizes dental-related services for adults, that authorization indicates only that the specific service is medically necessary; it is not a guarantee of payment. The client must be eligible for covered services at the time those services are provided.))

(1) The department uses the determination process described in WAC 388-501-0165 for covered dental-related services for clients age twenty-one and older that require prior authorization.

(2) ((MAA)) The department 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 ((Assoc6iation)) 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 when radiographs do not sufficiently support the medical necessity for extractions;

(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))

(3) The department may request additional information as follows:

(a) Additional radiographs (x-rays) (refer to WAC 388-535-1255(2));

(b) Study models;

(c) Photographs; and

(d) Any other information as determined by the department.

(4) The department may require second opinions and/or consultations before authorizing any procedure.

(5) When the department authorizes a dental-related service for a client, that authorization indicates only that the specific service is medically necessary, it is not a guarantee of payment. The authorization is valid for six months and only if the client is eligible for covered services on the date of service.

(6) The department denies a request for a dental-related service when the requested service:

(a) Is covered by another department program;

(b) Is covered by an agency or other entity outside the department; or

(c) Fails to meet the program criteria, limitations, or restrictions in chapter 388-535 WAC.

[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. 03-19-080, 388-535-1280, filed 9/12/03, effective 10/13/03.]


REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 388-535-1270 Dental-related services requiring prior authorization -- Adults.
WAC 388-535-1290 Dentures and partial dentures for adults.

Washington State Code Reviser's Office