PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: The new and amended sections clarify and update policies for dental-related services for clients through age twenty; 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 through age twenty; clarify policy for the ABCD program; and repeal WAC 388-535-1200, 388-535-1230, and 388-535-1240 and incorporate updated policy into new sections. Clients and dental providers will be able to identify the requirements and criteria that must be met in order to obtain covered dental-related services.
Citation of Existing Rules Affected by this Order: Repealing WAC 388-535-1200, 388-535-1230 and 388-535-1240; and amending WAC 388-535-1080, 388-535-1100, 388-535-1220, and 388-535-1245.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.500, 74.09.520.
Adopted under notice filed as WSR 06-24-069 (part 1 of 4), 06-24-068 (part 2 of 4), 06-24-071 (part 3 of 4), and 06-24-070 (part 4 of 4) on December 4, 2006.
Changes Other than Editing from Proposed to Adopted Version: Note: Strikeouts and underlines indicate language deleted or added since the proposal.
WAC 388-535-1079 Dental-related services for clients through age twenty--General. (1)(d) Are documented in the client's record in accordance with chapter 388-502 WAC;
(d) (e) Are within...;
(e) (f) Are consistent...;
(f) (g) Are reasonable...; and
(g) (h) Are listed...
(2) Under the Early Periodic Screening and Diagnostic
Treatment (EPSDT) program, clients ages twenty and younger may
be eligible for the dental-related services listed as
noncovered in WAC 388-535-1100, if the services include those
medically necessary services and other measures provided to
correct or ameliorate conditions discovered during a screening
performed under the EPSDT program.
WAC 388-535-1080 Covered dental-related services for
clients through age twenty--Diagnostic. (1)(a) Oral health
evaluations and assessments. The services must be documented
in the client's record in accordance with WAC 388-502-0020.
(2) Radiographs (X-rays). The department: ...(f) Covers a
maximum of two four bitewing radiographs once every twelve
months for clients through age eleven.
WAC 388-535-1082 Covered dental-related services for
clients through age twenty--Preventive services. (1)(a) Which
includes scaling and polishing...once every six months for
clients through age eighteen twenty. (b) Which includes
scaling and polishing procedures to remove coronal plague,
calculus, and stains when performed on transitional or
permanent dentition, once every twelve months for clients ages
nineteen through twenty.
(c) (b) Only when the service is performed six months
after periodontal scaling and root planing, or periodontal
maintenance services, for clients ages thirteen through
eighteen twenty.
(d) Only when the service is performed twelve months
after periodontal scaling and root planing, or periodontal
maintenance services for clients ages nineteen through twenty.
(e) (c) Only when not performed...scaling and root planing.
(f) (d) For clients of the division of developmental
disabilities...
(4)(d) Sealants only if evidence of occlusal or
interproximal decay has not penetrated to the dentoenamel
junction (DEJ). Sealants on noncarious teeth or teeth with
incipient caries.
WAC 388-535-1084 Covered dental-related services for
clients through age twenty--Restorative services. (3) Amalgam
restorations for primary posterior teeth only. The
department: (a) Ccovers amalgam restorations for a maximum of
two surfaces for a primary posterior tooth first molar and a
maximum of three surfaces for a primary second molar. (See
subsection (9)(c) of this section for restorations for a
primary posterior tooth requiring a three or more surface
restoration. additional surfaces.) The department does not
pay for additional amalgam restorations. (b) Does not pay for
additional amalgam or composite restoration on the same tooth
after two surfaces.
(6)(b) Resin-based composite restorations for a maximum
of two surfaces for a primary posterior tooth first molar and
a maximum of three surfaces for a primary second molar. (See
subsection (9)(c) of this subsection for restorations for a
primary posterior tooth requiring a three of [or] more surface
restoration additional surfaces.) The department does not pay
for additional composite or amalgon restorations on the same
tooth after two surfaces.
(6)(c) Glass ionimer restorations only for primary teeth,
and only for clients ages four five and younger...
(9)(c) Prefabricated stainless steel crowns for primary
posterior teeth once every three years without prior
authorization if: decay involves three or more surfaces, of if
the tooth had a pulpotomy. (i) Decay involves three or more
surfaces for a primary first molar; (ii) Decay involves four
or more surfaces for a primary second molar; or (iii) The
tooth had a pulpotomy.
WAC 388-535-1090 Covered dental-related services for
clients through age twenty--Prosthodontics (removable).
(1)(f) Requires a provider to submit the following with a
prior authorization request for removable prosthetics for a
client residing in a nursing home, group home, or other
facility an alternate living facility (ALF) as defined in WAC 388-513-1301 or in a nursing facility.
WAC 388-535-1098 Covered dental-related services for
clients through age twenty--Adjunctive general services.
(5)(a)(ii) Clients ages...when prior authorized; and (iii)
Clients of the division of developmental disabilities
according to WAC 388-535-1099.; and
(iv) Clients who reside in an alternate living facility (ALF) as defined in WAC 388-513-1301 or in a nursing facility.
WAC 388-535-1100 Dental-related services not covered for
clients through age twenty. (1)(a) The dental-related
services described in subsection (2) of this section unless
the services are covered include those medically necessary
services and other measures provided to correct or ameliorate
conditions discovered during a screening performed under the
early periodic screening, diagnosis and treatment (EPSDT)
program. See WAC 388-534-0100 for information about the EPSDT
program.
A final cost-benefit analysis is available by contacting Dr. John Davis, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1748, fax (360) 568-1590, e-mail davisjs@dshs.wa.gov.
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 0, Amended 0, Repealed 0.
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 11, Amended 4, Repealed 3.
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 11, Amended 4, Repealed 3.
Date Adopted: February 27, 2007.
Robin Arnold-Williams
Secretary
3804.6(a) Are within the scope of an eligible client's medical care program;
(b) Are medically necessary;
(c) Meet the department's prior authorization requirements, if any;
(d) Are documented in the client's record in accordance with chapter 388-502 WAC;
(e) Are within accepted dental or medical practice standards;
(f) Are consistent with a diagnosis of dental disease or condition;
(g) Are reasonable in amount and duration of care, treatment, or service; and
(h) Are listed as covered in the department's published rules, billing instructions and fee schedules.
(2) Under the Early Periodic Screening and Diagnostic Treatment (EPSDT) program, clients ages twenty and younger may be eligible for dental-related services listed as noncovered.
(3) Clients who are eligible for services through the division of developmental disabilities may receive dental-related services according to WAC 388-535-1099.
(4) 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 according to WAC 388-501-0160.
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(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 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 evaluation only when the provider performing the limited oral evaluation is not providing prescheduled 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 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 radiographs must be provided within fourteen days prior to surgery, and postoperative 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) Topical application of fluoride gel, once every six months; or
(ii) Topical application of fluoride varnish, up to three times in a twelve-month period;
(iii) See subsection (3) of this section for clients of the division of developmental disabilities.
(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 six months for children age eight through eighteen;
(ii) Only as a component of oral hygiene instruction for children through age seven; and
(iii) For clients of the division of developmental disabilities, see subsection (3) of this section.
(g) Space maintainers, for children through age eighteen only, as follows:
(i) Fixed (unilateral type), one per quadrant;
(ii) Fixed (bilateral type), one per arch; and
(iii) Recementation of space maintainer, 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 multisurface restoration, and are reimbursed as such; and
(ii) Proximal restorations that do not involve the incisal 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) 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 prophylaxis, periodontal maintenance, gingivectomy, or gingivoplasty.
(o) Periodontal maintenance as follows:
(i) 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 full mouth in a twelve-month period; and
(iv) Not allowed when performed on the same date of service as prophylaxis, periodontal scaling, gingivectomy, or gingivoplasty..
(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 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 when requested by the client or the client's surrogate decision maker as defined in WAC 388-97-055, or when a referral for services is 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.
(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, allowed three times per calendar year;
(b) Prophylaxis, allowed three times per calendar year;
(c) Periodontal scaling and root planing, allowed once every six months;
(d) Periodontal maintenance, allowed three times every twelve months;
(e) Nitrous oxide;
(f) Behavior management that requires the assistance of one additional dental professional staff; and
(g) 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
(v) A general dentist who has a current conscious sedation permit from the department of health (DOH).
(b) MAA pays for anesthesia services 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 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)) The department covers medically necessary dental-related diagnostic services, subject to the coverage limitations listed, for clients through age twenty as follows:
(1) Clinical oral evaluations. The department covers:
(a) Oral health evaluations and assessments.
(b) Periodic oral evaluations as defined in WAC 388-535-1050, once every six months. Six 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 any additional limited examination by a denturist for the same client until three months after a 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 oral evaluation services;
(ii) Performed to determine the need for sealants or 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 requested.
(b) Uses the prevailing standard of care to determine the need for dental radiographs.
(c) Covers an 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 included in the client's record.
(e) Covers an occlusal intraoral radiograph once in a two-year period. Documentation supporting the medical necessity for these must be included in the client's record.
(f) Covers a maximum of four bitewing radiographs once every twelve months for clients through age eleven.
(g) Covers a maximum of four bitewing radiographs once every twelve months for clients ages twelve through twenty.
(h) 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.
(i) 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.
(j) Covers cephalometric film:
(i) For orthodontics, as described in chapter 388-535A WAC; or
(ii) Only on a case-by-case basis and when prior authorized.
(k) Covers radiographs not listed as covered in this subsection, only on a case-by-case basis and when prior authorized.
(l) Covers oral and facial photographic images, only on a case-by-case basis and when requested by the department.
(3) Tests and examinations. The department covers:
(a) One pulp vitality test per visit (not per tooth):
(i) For diagnosis only during limited oral evaluations; and
(ii) When radiographs and/or documented symptoms justify the medical necessity for the pulp vitality test.
(b) Diagnostic casts other than those included in an orthodontic case study, on a case-by-case basis, and when requested by the department.
[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. 03-19-078, § 388-535-1080, 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, § 388-535-1080, 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.]
(1) Dental prophylaxis. The department covers prophylaxis:
(a) Which includes scaling and polishing procedures to remove coronal plaque, calculus, and stains when performed on primary, transitional, or permanent dentition, once every six months for clients through age twenty.
(b) Only when the service is performed six months after periodontal scaling and root planing, or periodontal maintenance services, for clients ages thirteen through twenty.
(c) Only when not performed on the same date of service as periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty.
(d) For clients of the division of developmental disabilities according to WAC 388-535-1099.
(2) Topical fluoride treatment. The department covers:
(a) Fluoride varnish, rinse, foam or gel for clients ages six and younger, up to three times within a twelve-month period.
(b) Fluoride varnish, rinse, foam or gel for clients ages seven through eighteen, up to two times within a twelve-month period.
(c) Fluoride varnish, rinse, foam or gel, up to three times within a twelve-month period during orthodontic treatment.
(d) Fluoride rinse, foam or gel for clients ages nineteen through twenty, once within a twelve-month period.
(e) Additional topical fluoride applications only on a case-by-case basis and when prior authorized.
(f) Topical fluoride treatment for clients of the division of developmental disabilities according to WAC 388-535-1099.
(3) Oral hygiene instruction. The department covers:
(a) Oral hygiene instruction only for clients through age eight.
(b) Oral hygiene instruction up to two times within a twelve-month period.
(c) Individualized oral hygiene instruction for home care to include tooth brushing technique, flossing, and use of oral hygiene aides.
(d) Oral hygiene instruction only when not performed on the same date of service as prophylaxis.
(e) Oral hygiene instruction only when provided by a licensed dentist or a licensed dental hygienist and the instruction is provided in a setting other than a dental office or clinic.
(4) Sealants. The department covers:
(a) Sealants only when used on a mechanically and/or chemically prepared enamel surface.
(b) Sealants once per tooth in a three-year period for clients through age eighteen.
(c) Sealants only when used on the occlusal surfaces of:
(i) Permanent teeth two, three, fourteen, fifteen, eighteen, nineteen, thirty, and thirty-one; and
(ii) Primary teeth A, B, I, J, K, L, S, and T.
(d) Sealants on noncarious teeth or teeth with incipient caries.
(e) Sealants only when placed on a tooth with no pre-existing occlusal restoration, or any occlusal restoration placed on the same day.
(f) Additional sealants on a case-by-case basis and when prior authorized.
(5) Space maintenance. The department covers:
(a) Fixed unilateral or fixed bilateral space maintainers for clients through age eighteen.
(b) Only one space maintainer per quadrant.
(c) Space maintainers only for missing primary molars A, B, I, J, K, L, S, and T.
(d) Replacement space maintainers only on a case-by-case basis and when prior authorized.
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3805.7(1) Restorative/operative procedures. The department covers restorative/operative procedures performed in a hospital or an ambulatory surgical center for:
(a) Clients ages eight and younger;
(b) Clients ages nine through twenty only on a case-by-case basis and when prior authorized; and
(c) Clients of the division of developmental disabilities according to WAC 388-535-1099.
(2) Amalgam restorations for primary and permanent teeth. The department considers:
(a) Tooth preparation, all adhesives (including amalgam bonding agents), liners, bases, and polishing as part of the amalgam restoration.
(b) The occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of the amalgam restoration.
(c) Buccal or lingual surface amalgam restorations, regardless of size or extension, as a one surface restoration. The department covers one buccal and one lingual surface per tooth.
(d) Multiple amalgam restorations of fissures and grooves of the occlusal surface of the same tooth as a one surface restoration.
(e) Amalgam restorations placed within six months of a crown preparation by the same provider or clinic to be included in the payment for the crown.
(3) Amalgam restorations for primary posterior teeth only. The department covers amalgam restorations for a maximum of two surfaces for a primary first molar and maximum of three surfaces for a primary second molar. (See subsection (9)(c) of this section for restorations for a primary posterior tooth requiring additional surfaces.) The department does not pay for additional amalgam restorations.
(4) Amalgam restorations for permanent posterior teeth only. The department:
(a) Covers two occlusal amalgam restorations for teeth one, two, three fourteen, fifteen, and sixteen, if the restorations are anatomically separated by sound tooth structure.
(b) 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.
(c) 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 (a) of this subsection).
(d) Does not pay for replacement of amalgam restoration on permanent posterior 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.
(5) Resin-based composite restorations for primary and 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 (see WAC 388-535-1082(4) for sealants coverage).
(e) Considers multiple preventive restorative resin, flowable composite resin, or resin-based composites 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) when performed on posterior teeth or the incisal surface of anterior teeth.
(g) Considers resin-based composite restorations placed within six months of a crown preparation by the same provider or clinic to be included in the payment for the crown.
(6) Resin-based composite restorations for primary teeth only. The department covers:
(a) Resin-based composite restorations for a maximum of three surfaces for a primary anterior tooth (see subsection (9)(b) of this section for restorations for a primary anterior tooth requiring a four or more surface restoration). The department does not pay for additional composite or amalgam restorations on the same tooth after three surfaces.
(b) Resin-based composite restorations for a maximum of two surfaces for a primary first molar and a maximum of three surfaces for a primary second molar. (See subsection (9)(c) of this subsection for restorations for a primary posterior tooth requiring additional surfaces.) The department does not pay for additional composite restorations on the same tooth.
(c) Glass ionimer restorations only for primary teeth, and only for clients ages five and younger. The department pays for these restorations as a one surface resin-based composite restoration.
(7) Resin-based composite restorations for permanent teeth only. The department covers:
(a) Two occlusal resin-based composite restorations for teeth one, two, fourteen, fifteen, and sixteen if the restorations are anatomically separated by sound tooth structure.
(b) 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.
(c) 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 (a) of this subsection).
(d) 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.
(e) Replacement of resin-based composite restoration on permanent teeth within a two-year period only if the restoration has an additional adjoining carious surface. The department pays the replacement restoration as a one multi-surface restoration. The client's record must include radiographs and documentation supporting the medical necessity for the replacement restoration.
(8) Crowns. The department:
(a) Covers the following crowns once every five years, per tooth, for permanent anterior teeth for clients ages twelve through twenty when the crowns meet prior authorization criteria in WAC 388-535-1220 and the provider follows the prior authorization requirements in (d) of this subsection:
(i) Porcelain/ceramic crowns to include all porcelains, glasses, glass-ceramic, and porcelain fused to metal crowns; and
(ii) Resin crowns and resin metal crowns to include any resin-based composite, fiber, or ceramic reinforced polymer compound.
(b) Covers full coverage metal crowns once every five years, per tooth, for permanent posterior teeth to include high noble, titanium, titanium alloys, noble, and predominantly base metal crowns for clients ages eighteen through twenty when they meet prior authorization criteria and the provider follows the prior authorization requirements in (d) and (e) of this subsection.
(c) Considers the following to be included in the payment for a crown:
(i) Tooth and soft tissue preparation;
(ii) Amalgam and resin-based composite restoration, or any other restorative material placed within six months of the crown preparation. Exception: The department covers a one surface restoration on an endodontically treated tooth, or a core buildup or cast post and core;
(iii) Temporaries, including but not limited to, temporary restoration, temporary crown, provisional crown, temporary prefabricated stainless steel crown, ion crown, or acrylic crown;
(iv) Packing cord placement and removal;
(v) Diagnostic or final impressions;
(vi) Crown seating, including cementing and insulating bases;
(vii) Occlusal adjustment of crown or opposing tooth or teeth; and
(viii) Local anesthesia.
(d) Requires the provider to submit the following with each prior authorization request:
(i) Radiographs to assess all remaining teeth;
(ii) Documentation and identification of all missing teeth;
(iii) Caries diagnosis and treatment plan for all remaining teeth, including a caries control plan for clients with rampant caries;
(iv) Pre- and post-endodontic treatment radiographs for requests on endodontically treated teeth; and
(v) Documentation supporting a five-year prognosis that the client will retain the tooth or crown if the tooth is crowned.
(e) Requires a provider to bill for a crown only after delivery and seating of the crown, not at the impression date.
(9) Other restorative services. The department covers:
(a) All recementations of permanent indirect crowns.
(b) Prefabricated stainless steel crowns with resin window, resin-based composite crowns, prefabricated esthetic coated stainless steel crowns, and fabricated resin crowns for primary anterior teeth once every three years without prior authorization if the tooth requires a four or more surface restoration.
(c) Prefabricated stainless steel crowns for primary posterior teeth once every three years without prior authorization if:
(i) Decay involves three or more surfaces for a primary first molar;
(ii) Decay involves four or more surfaces for a primary second molar; or
(iii) The tooth had a pulpotomy.
(d) Prefabricated stainless steel crowns for permanent posterior teeth once every three years when prior authorized.
(e) Prefabricated stainless steel crowns for clients of the division of developmental disabilities according to WAC 388-535-1099.
(f) Core buildup, including pins, only on permanent teeth, when prior authorized at the same time as the crown prior authorization.
(g) Cast post and core or prefabricated post and core, only on permanent teeth, when prior authorized at the same time as the crown prior authorization.
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(1) Pulp capping. The department considers pulp capping to be included in the payment for the restoration.
(2) Pulpotomy. The department covers:
(a) Therapeutic pulpotomy on primary posterior teeth only; and
(b) Pulpal debridement on permanent teeth only, excluding teeth one, sixteen, seventeen, and thirty-two. The department does not pay for pulpal debridement when performed with palliative treatment of dental pain or when performed on the same day as endodontic treatment.
(3) Endodontic treatment. The department:
(a) Covers endodontic treatment with resorbable material for primary maxillary incisor teeth D, E, F, and G, if the entire root is present at treatment.
(b) Covers endodontic treatment for permanent anterior, bicuspid, and molar teeth, excluding teeth one, sixteen, seventeen, and thirty-two.
(c) 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.
(d) 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.
(e) 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 anterior, bicuspid, and molar teeth, excluding teeth one, sixteen, seventeen, and thirty-two.
(f) 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.
(g) Does not pay for endodontic retreatment when provided by the original treating provider or clinic unless prior authorized by the department.
(h) Covers apexification for apical closures for anterior permanent teeth only on a case-by-case basis and when prior authorized. Apexification is limited to the initial visit and three interim treatment visits.
(i) Covers apicoectomy and a retrograde fill for anterior teeth only.
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(1) Surgical periodontal services. The department covers the following surgical periodontal services, including all postoperative care:
(a) Gingivectomy/gingivoplasty only on a case-by-case basis and when prior authorized; and
(b) Gingivectomy/gingivoplasty for clients of the division of developmental disabilities according to WAC 388-535-1099.
(2) Nonsurgical periodontal services. The department:
(a) Covers periodontal scaling and root planing once per quadrant, per client in a two-year period on a case-by-case basis, when prior authorized for clients ages thirteen through eighteen, and only when:
(i) The client has radiographic evidence of periodontal disease;
(ii) The client's record includes supporting documentation for the medical necessity, including complete periodontal charting and a definitive diagnosis of periodontal disease;
(iii) The client's clinical condition meets current published periodontal guidelines; and
(iv) Performed at least two years from the date of completion of periodontal scaling and root planing or surgical periodontal treatment.
(b) Covers periodontal scaling and root planing once per quadrant, per client, in a two-year period for clients ages nineteen through twenty. Criteria in (a)(i) through (iv) of this subsection must be met.
(c) Considers ultrasonic scaling, gross scaling, or gross debridement to be included in the procedure and not a substitution for periodontal scaling and root planing.
(d) Covers periodontal scaling and root planing only when the services are not performed on the same date of service as prophylaxis, periodontal maintenance, gingivectomy, or gingivoplasty.
(e) Covers periodontal scaling and root planing for clients of the division of developmental disabilities according to WAC 388-535-1099.
(3) Other periodontal services. The department:
(a) Covers periodontal maintenance once per client in a twelve-month period on a case-by-case basis, when prior authorized, for clients ages thirteen through eighteen, and only when:
(i) The client has radiographic evidence of periodontal disease;
(ii) The client's record includes supporting documentation for the medical necessity, including complete periodontal charting and a definitive diagnosis of periodontal disease;
(iii) The client's clinical condition meets current published periodontal guidelines; and
(iv) Performed at least twelve months from the date of completion of periodontal scaling and root planing, or surgical periodontal treatment.
(b) Covers periodontal maintenance once per client in a twelve month period for clients ages nineteen through twenty. Criteria in (a)(i) through (iv) of this subsection must be met.
(c) Covers periodontal maintenance only if performed on a different date of service as prophylaxis, periodontal scaling and root planing, gingivectomy, or gingivoplasty.
(d) Covers periodontal maintenance for clients of the division of developmental disabilities according to WAC 388-535-1099.
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(1) Prosthodontics. The department:
(a) Requires prior authorization for all removable prosthodontic and prosthodontic-related procedures, except as stated in (c)(ii)(B) of this subsection. Prior authorization requests must meet the criteria in WAC 388-535-1220. In addition, the department requires the dental provider to submit:
(i) Appropriate and diagnostic radiographs of all remaining teeth.
(ii) A dental record which identifies:
(A) All missing teeth for both arches;
(B) Teeth that are to be extracted; and
(C) Dental and periodontal services completed on all remaining teeth.
(iii) A prescription written by a dentist when a denturist's prior authorization request is for an immediate denture or a cast metal partial denture.
(b) Covers complete dentures, as follows:
(i) A complete denture, including an immediate denture or overdenture, is covered when prior authorized.
(ii) Three-month post-delivery care (e.g., adjustments, soft relines, and repairs) from the seat date of the complete denture, is considered part of the complete denture procedure and is not paid separately.
(iii) Replacement of an immediate denture with a complete denture is covered if the complete denture is prior authorized at least six months after the seat date of the immediate denture.
(iv) Replacement of a complete denture or overdenture is covered only if prior authorized at least five years after the seat date of the complete denture or overdenture being replaced. The replacement denture must be prior authorized.
(c) Covers partial dentures, as follows:
(i) A partial denture, including a resin or flexible base partial denture, is covered for anterior and posterior teeth when the partial denture meets the following department coverage criteria.
(A) The remaining teeth in the arch must have a reasonable periodontal diagnosis and prognosis;
(B) The client has established caries control;
(C) One or more anterior teeth are missing or four or more posterior teeth are missing;
(D) There is a minimum of four stable teeth remaining per arch; and
(E) There is a three-year prognosis for retention of the remaining teeth.
(ii) Prior authorization of partial dentures:
(A) Is required for clients ages nine and younger; and
(B) Not required for clients ages ten through twenty. Documentation supporting the medical necessity for the service must be included in the client's file.
(iii) Three-month post-delivery care (e.g., adjustments, soft relines, and repairs) from the seat date of the partial denture, is considered part of the partial denture procedure and is not paid separately.
(iv) Replacement of a resin or flexible base denture is covered only if prior authorized at least three years after the seat date of the resin or flexible base partial denture being replaced. The replacement denture must be prior authorized and meet department coverage criteria in (c)(i) of this subsection.
(d) Covers cast-metal framework partial dentures, as follows:
(i) Cast-metal framework with resin-based partial dentures, including any conventional clasps, rests, and teeth, are covered for clients ages eighteen through twenty only once in a five-year period, on a case-by-case basis, when prior authorized and department coverage criteria listed in subsection (d)(v) of this subsection are met.
(ii) Cast-metal framework partial dentures for clients ages seventeen and younger are not covered.
(iii) Three-month post-delivery care (e.g., adjustments, soft relines, and repairs) from the seat date of the cast metal partial denture is considered part of the partial denture procedure and is not paid separately.
(iv) Replacement of a cast metal framework partial denture is covered on a case-by-case basis and only if placed at least five years after the seat date of the partial denture being replaced. The replacement denture must be prior authorized and meet department coverage criteria listed in (d)(v) of this subsection.
(v) Department authorization and payment for cast metal framework partial dentures is based on the following criteria:
(A) The remaining teeth in the arch must have a stable periodontal diagnosis and prognosis;
(B) The client has established caries control;
(C) All restorative and periodontal procedures must be completed before the request for prior authorization is submitted;
(D) There are fewer than eight posterior teeth in occlusion;
(E) There is a minimum of four stable teeth remaining per arch; and
(F) There is a five-year prognosis for the retention of the remaining teeth.
(vi) The department may consider resin partial dentures as an alternative if the department determines the criteria for cast metal framework partial dentures listed in (d)(v) of this subsection are not met.
(e) Requires a provider to bill for removable prosthetic procedures only after the seating of the prosthesis, not at the impression date. Refer to subsection (2)(e) and (f) for what the department may pay if the removable prosthesis is not delivered and inserted.
(f) Requires a provider to submit the following with a prior authorization request for removable prosthetics for a client residing in an alternate living facility (ALF) as defined in WAC 388-513-1301 or in a nursing facility:
(i) The client's medical diagnosis or prognosis;
(ii) The attending physician's request for prosthetic services;
(iii) The attending dentist's or denturist's statement documenting medical necessity;
(iv) A written and signed consent for treatment from the client's legal guardian when a guardian has been appointed; and
(v) A completed copy of the Denture/Partial Appliance Request for Skilled Nursing Facility Client form (DSHS 13-788) available from the department's published billing instructions.
(g) Limits removable partial dentures to resin-based partial dentures for all clients residing in one of the facilities listed in (f) of this subsection. The department may consider cast metal partial dentures if the criteria in subsection (1)(d) are met.
(h) Requires a provider to deliver services and procedures that are of acceptable quality to the department. The department may recoup payment for services that are determined to be below the standard of care or of an unacceptable product quality.
(2) Other services for removable prosthodontics. The department covers:
(a) Adjustments to complete and partial dentures three months after the date of delivery.
(b) Repairs to complete and partial dentures, once in a twelve month period. The department covers additional repairs on a case-by-case basis and when prior authorized.
(c) A laboratory reline or rebase to a complete or cast-metal partial denture, once in a three-year period when performed at least six months after the seating date. An additional reline or rebase may be covered for complete or cast-metal partial dentures on a case-by-case basis when prior authorized.
(d) Up to two tissue conditionings, and only when performed within three months after the seating date.
(e) Laboratory fees, subject to the following:
(i) The department does not pay separately for laboratory or professional fees for complete and partial dentures; and
(ii) The department may pay part of billed laboratory fees when the provider obtains prior authorization, and the client:
(A) Is not eligible at the time of delivery of the prosthesis;
(B) Moves from the state;
(C) Cannot be located;
(D) Does not participate in completing the complete, immediate, or partial dentures; or
(E) Dies.
(f) A provider must submit copies of laboratory prescriptions and receipts or invoices for each claim when billing for laboratory fees.
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3806.5(1) Maxillofacial prosthetics are covered only on a case-by-case basis and when prior authorized; and
(2) The department must pre-approve a provider qualified to furnish maxillofacial prosthetics.
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(1) Oral and maxillofacial surgery services. The department:
(a) Requires enrolled providers who do not meet the conditions in WAC 388-535-1070(3) to bill claims for services that are listed in this subsection using only the Current Dental Terminology (CDT) codes.
(b) Requires enrolled providers (oral and maxillofacial surgeons) who meet the conditions in WAC 388-535-1070(3) to bill claims using Current Procedural Terminology (CPT) codes unless the procedure is specifically listed in the department's current published billing instructions as a CDT covered code (e.g., extractions).
(c) Covers nonemergency oral surgery performed in a hospital or ambulatory surgery center only for:
(i) Clients ages eight and younger;
(ii) Clients ages nine through twenty only on a case-by-case basis and when prior authorized; and
(iii) Clients of the division of developmental disabilities according to WAC 388-535-1099.
(d) Requires the client's dental record to include supporting documentation for each type of extraction or any other surgical procedure billed to the department. The documentation must include:
(i) Appropriate consent form signed by the client or the client's legal representative;
(ii) Appropriate radiographs;
(iii) Medical justification with diagnosis;
(iv) Client's blood pressure, when appropriate;
(v) A surgical narrative;
(vi) A copy of the post-operative instructions; and
(vii) A copy of all pre- and post-operative prescriptions.
(e) Covers routine and surgical extractions.
(f) Covers debridement of a granuloma or cyst that is five millimeters or greater in diameter. The department includes debridement of a granuloma or cyst that is less than five millimeters as part of the global fee for the extraction.
(g) Covers biopsy, as follows:
(i) Biopsy of soft oral tissue or brush biopsy do not require prior authorization; and
(ii) All biopsy reports or findings must be kept in the client's dental record.
(h) Covers alveoloplasty only on a case-by-case basis and when prior authorized. The department covers alveoplasty only when not performed in conjunction with extractions.
(i) Covers surgical excision of soft tissue lesions only on a case-by-case basis and when prior authorized.
(j) Covers only the following excisions of bone tissue in conjunction with placement of immediate, complete, or partial dentures when prior authorized:
(i) Removal of lateral exostosis;
(ii) Removal of torus palatinus or torus mandibularis; and
(iii) Surgical reduction of soft tissue or osseous tuberosity.
(2) Surgical incisions. The department covers the following surgical incision-related services:
(a) Uncomplicated intraoral and extraoral soft tissue incision and drainage of abscess. The department does not cover this service when combined with an extraction or root canal treatment. Documentation supporting medical necessity must be in the client's record.
(b) Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue when prior authorized. Documentation supporting the medical necessity for the service must be in the client's record.
(c) Frenuloplasty/frenulectomy for clients through age six. The department covers frenuloplasty/frenulectomy for clients ages seven through twelve only on a case-by-case and when prior authorized. Documentation supporting the medical necessity for the service must be in the client's record.
(3) Occlusal orthotic devices. (Refer to WAC 388-535-1098 (5)(c) for occlusal guard coverage and limitations on coverage.) The department covers:
(a) Occlusal orthotic devices for clients ages twelve through twenty only on a case-by-case basis and when prior authorized.
(b) An occlusal orthotic device only as a laboratory processed full arch appliance.
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(1) Adjunctive general services. The department:
(a) Covers palliative (emergency) treatment, not to include pupal debridement (see WAC 388-535-1086 (2)(b)), for treatment of dental pain, limited to once per day, per client, as follows:
(i) The treatment must occur during limited evaluation appointments;
(ii) A comprehensive description of the diagnosis and services provided must be documented in the client's record; and
(iii) Appropriate radiographs must be in the client's record supporting the medical necessity of the treatment.
(b) Covers local anesthesia and regional blocks as part of the global fee for any procedure being provided to clients.
(c) Covers office based oral or parenteral conscious sedation, deep sedation, or general anesthesia, as follows:
(i) The provider's current anesthesia permit must be on file with the department.
(ii) For clients of the division of developmental disabilities, the services must be performed according to WAC 388-535-1099.
(iii) For clients ages eight and younger, documentation supporting the medical necessity of the anesthesia service must be in the client's record.
(iv) For clients ages nine through twenty, deep sedation or general anesthesia services are covered on a case-by-case basis and when prior authorized, except for oral surgery services. Oral surgery services listed in WAC 388-535-1094 do not require prior authorization.
(v) Prior authorization is not required for oral or parenteral conscious sedation for any dental service. Documentation supporting the medical necessity of the service must be in the client's record.
(vi) For clients ages nine through eighteen who have a diagnosis of oral facial cleft, the department does not require prior authorization for deep sedation or general anesthesia services when the dental procedure is directly related to the oral facial cleft treatment.
(vii) For clients through age twenty, the provider must bill anesthesia services using the CDT codes listed in the department's current published billing instructions.
(d) Covers inhalation of nitrous oxide for clients through age twenty, once per day.
(e) Requires providers of oral or parenteral conscious sedation, deep sedation, or general anesthesia to meet:
(i) The prevailing standard of care;
(ii) The provider's professional organizational guidelines;
(iii) The requirements in chapter 246-817 WAC; and
(iv) Relevant department of health (DOH) medical, dental, or nursing anesthesia regulations.
(f) Pays for anesthesia services according to WAC 388-535-1350.
(g) Covers professional consultation/diagnostic services as follows:
(i) A dentist or a physician other than the practitioner providing treatment must provide the services; and
(ii) A client must be referred by the department for the services to be covered.
(2) Nonemergency dental services. The department covers nonemergency dental services performed in a hospital or ambulatory surgical center only for:
(a) Clients ages eight and younger.
(b) Clients ages nine through twenty only on a case-by-case basis and when prior authorized.
(c) Clients of the division of developmental disabilities according to WAC 388-535-1099.
(3) Professional visits. The department covers:
(a) Up to two house/extended care facility calls (visits) per facility, per provider. The department limits payment to two facilities per day, per provider.
(b) One hospital call (visit), including emergency care, per day, per provider, per client.
(c) Emergency office visits after regularly scheduled hours. The department limits payment to one emergency visit per day, per provider.
(4) Drugs and/or medicaments (pharmaceuticals). The department covers drugs and/or medicaments only when used with parenteral conscious sedation, deep sedation, or general anesthesia. The department's dental program does not pay for oral sedation medications.
(5) Miscellaneous services. The department covers:
(a) Behavior management when the assistance of one additional dental staff other than the dentist is required, for:
(i) Clients ages eight and younger;
(ii) Clients ages nine through twenty, only on a case-by-case basis and when prior authorized;
(iii) Clients of the division of developmental disabilities according to WAC 388-535-1099; and
(iv) Clients who reside in an alternate living facility (ALF) as defined in WAC 388-513-1301 or in a nursing facility.
(b) Treatment of post-surgical complications (e.g., dry socket). Documentation supporting the medical necessity of the service must be in the client's record.
(c) Occlusal guards when medically necessary and prior authorized. (Refer to WAC 388-535-1094(3) for occlusal orthotic device coverage and coverage limitations.) The department covers:
(i) An occlusal guard only for clients ages twelve through twenty when the client has permanent dentition; and
(ii) An occlusal guard only as a laboratory processed full arch appliance.
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(1) Preventive services.
(a) Dental prophylaxis. The department covers dental prophylaxis or periodontal maintenance up to three times in a twelve-month period (see subsection (3) of this section for limitations on periodontal scaling and root planing).
(b) Topical fluoride treatment. The department covers topical fluoride varnish, rinse, foam or gel, up to three times within a twelve-month period.
(c) Sealants. The department covers sealants:
(i) Only when used on the occlusal surfaces of:
(A) Primary teeth A, B, I, J, K, L, S, and T; or
(B) Permanent teeth two, three, four, five, twelve, thirteen, fourteen, fifteen, eighteen, nineteen, twenty, twenty-one, twenty-eight, twenty-nine, thirty, and thirty-one.
(ii) Once per tooth in a two-year period.
(2) Crowns. The department covers stainless steel crowns every two years for the same tooth and only for primary molars and permanent premolars and molars, as follows:
(a) For clients ages twenty and younger, the department does not require prior authorization for stainless steel crowns. Documentation supporting the medical necessity of the service must be in the client's record.
(b) For clients ages twenty-one and older, the department requires prior authorization for stainless steel crowns.
(3) Periodontic services.
(a) Surgical periodontal services. The department covers:
(i) Gingivectomy/gingivoplasty once every three years. Documentation supporting the medical necessity of the service must be in the client's record (e.g., drug induced gingival hyperplasia).
(ii) Gingivectomy/gingivoplasty with periodontal scaling and root planing or periodontal maintenance when the services are performed:
(A) In a hospital or ambulatory surgical center; or
(B) For clients under conscious sedation, deep sedation, or general anesthesia.
(b) Nonsurgical periodontal services. The department covers:
(i) Periodontal scaling and root planing, up to two times per quadrant in a twelve-month period.
(ii) Periodontal scaling (four quadrants) substitutes for an eligible periodontal maintenance or oral prophylaxis, twice in a twelve-month period.
(4) Adjunctive general services.
(a) Adjunctive general services. The department covers:
(i) Oral parenteral conscious sedation, deep sedation, or general anesthesia for any dental services performed in a dental office or clinic. Documentation supporting the medical necessity must be in the client's record.
(ii) Sedations services according to WAC 388-535-1098 (1)(c) and (e).
(b) Nonemergency dental services. The department covers nonemergency dental services performed in a hospital or an ambulatory surgical center for services listed as covered in WAC 388-535-1082, WAC 388-535-1084, WAC 388-535-1086, WAC 388-535-1088, and WAC 388-535-1094. Documentation supporting the medical necessity of the service must be included in the client's record.
(5) Miscellaneous services--Behavior management. The department covers behavior management provided in dental offices or dental clinics for clients of any age. Documentation supporting the medical necessity of the service must be included in the client's record.
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3807.5(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.
(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 clients age nineteen 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.
(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, 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 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)) department does not cover the following for clients through age twenty:
(a) The dental-related services described in subsection (2) of this section unless the services are covered under the early periodic screening, diagnosis and treatment (EPSDT) program. See WAC 388-534-0100 for information about the EPSDT program.
(b) Any service specifically excluded by statute.
(c) More costly services when less costly, equally effective services as determined by the department are available.
(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 current published documents.
(2) The department does not cover dental-related services listed under the following categories of service for clients through age twenty (see subsection (1)(a) of this section for services provided under the EPSDT program):
(a) Diagnostic services. The department does not cover:
(i) Extraoral radiographs.
(ii) Comprehensive periodontal evaluations.
(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) Removable space maintainers of any type.
(iv) Sealants placed on a tooth with the same-day occlusal restoration, pre-existing occlusal restoration, or a tooth with occlusal decay.
(v) Space maintainers for clients ages nineteen through twenty.
(c) Restorative services. The department does not cover:
(i) Gold foil restorations.
(ii) Metallic, resin-based composite, or porcelain/ceramic inlay/onlay restorations.
(iii) Crowns for cosmetic purposes (e.g., peg laterals and tetracycline staining).
(iv) Crowns for third molars one, sixteen, seventeen, and thirty-two.
(v) Temporary or provisional crowns (including ion crowns).
(vi) Labial veneer resin or porcelain laminate restorations.
(vii) Any type of coping.
(viii) Crown repairs.
(ix) Polishing or recontouring restorations or overhang removal for any type of restoration.
(d) Endodontic services. The department does not cover:
(i) Any endodontic therapy on primary teeth, except as described in WAC 388-535-1086 (3)(a).
(ii) Apexification/recalcification for root resorption of permanent anterior teeth.
(iii) Any apexification/recalcification procedures for bicuspid or molar teeth.
(iv) Any apicoectomy/periradicular services for bicuspid or molar teeth.
(v) Any surgical endodontic procedures including, but not limited to, retrograde fillings (except for anterior teeth), root amputation, reimplantation, and hemisections.
(e) Periodontic services. The department does not cover:
(i) Surgical periodontal services including, but not limited to:
(A) Gingival flap procedures.
(B) Clinical crown lengthening.
(C) 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.
(H) Distal or proximal wedge procedures.
(ii) Nonsurgical periodontal services including, but not limited to:
(A) Intracoronal or extracoronal provisional splinting.
(B) Full mouth or quadrant debridement.
(C) Localized delivery of chemotherapeutic agents.
(D) Any other type of nonsurgical periodontal service.
(f) Removable prosthodontics. The department does not cover:
(i) Removable unilateral partial dentures.
(ii) Any interim complete or partial dentures.
(iii) Precision attachments.
(iv) Replacement of replaceable parts for semi-precision or precision attachments.
(g) Implant services. The department does not cover:
(i) Any type of 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 (g)(i) of this subsection.
(iii) The removal of any implant as described in (g)(i) of this subsection.
(h) Fixed prosthodontics. The department does not cover:
(i) Any type of fixed partial denture pontic or fixed partial denture retainer.
(ii) Any type of precision attachment, stress breaker, connector bar, coping, cast post, or any other type of fixed attachment or prosthesis.
(i) Oral and maxillofacial surgery. The department does not cover:
(i) Any oral surgery service not listed in WAC 388-535-1094.
(ii) 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.
(j) Adjunctive general services. The department does not cover:
(i) Anesthesia, including, but not limited to:
(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) Medication for oral sedation, or therapeutic intramuscular (IM) drug injections, including antibiotic and injection of sedative.
(E) Application of any type of desensitizing medicament or resin.
(ii) Other general services including, but not limited to:
(A) Fabrication of an athletic mouthguard.
(B) Occlusion analysis.
(C) Occlusal adjustment or odontoplasties.
(D) Enamel microabrasion.
(E) Dental supplies such as 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) Fees for no-show, cancelled, or late arrival appointments.
(M) Service charges of any type, including fees to create or copy charts.
(N) Office supplies used in conjunction with an office visit.
(O) Teeth whitening services or bleaching, or materials used in whitening or bleaching.
[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. 03-19-078, § 388-535-1100, 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, § 388-535-1100, 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) MAA)) (1) The department uses the determination process for payment described in WAC 388-501-0165 for covered dental-related services for clients through age twenty that require prior authorization.
(2) 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
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:))
(3) The department may request additional information as follows:
(a) ((Physiological description of the disease, injury,
impairment, or other ailment;
(b))) Additional radiographs (x-rays)(refer to WAC 388-535-1080(2)).;
(((c) Treatment plan;
(d))) (b) Study models ((, if requested)); ((and
(e))) (c) Photographs((, if requested)); and
(d) Any other information as determined by the department.
(4) The department may require second opinions and/or consultations before authorizing any procedure.
(((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)) (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. 03-19-078, § 388-535-1220, 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, § 388-535-1220, 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.]
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 02-11-136, filed 5/21/02,
effective 6/21/02)
WAC 388-535-1245
Access to baby and child dentistry
(ABCD) program.
The access to baby and child dentistry (ABCD)
program is a program established to increase access to dental
services ((in targeted areas)) for Medicaid-eligible
((infants, toddlers, and preschoolers. Public and private
sectors cooperate to administer the program)) clients ages
five and younger.
(1) Client eligibility for the ABCD program is as follows:
(a) Clients must be age five ((years of age or)) and
younger ((and reside in targeted areas selected by the medical
assistance administration (MAA))). Once enrolled in the ABCD
program, ((an)) eligible clients ((is)) are covered until
((reaching age six)) their sixth birthday.
(b) ((Eligible clients enrolled in a managed care plan
are eligible for the ABCD program under fee-for-service.
(c) Eligible)) Clients ((enrolled in)) eligible under one
of the following medical assistance programs are eligible for
the ABCD program:
(i) Categorically needy program (((CN or)) CNP);
(ii) Limited casualty program((/))-medically needy
program (LCP((/))-MNP); ((and))
(iii) Children's health program; or
(iv) State children's health insurance program (SCHIP).
(c) ABCD program services for eligible clients enrolled in a managed care organization (MCO) plan are paid through the fee-for-service payment system.
(2) Health care providers and community service programs
((in the targeted areas)) identify and refer eligible clients
to the ABCD program. If enrolled, the client and an adult
family member may receive:
(a) ((An ABCD program identification card;
(b))) Oral health ((information)) education;
(((c))) (b) "Anticipatory guidance" (expectations of the
client and the client's family members, including the
importance of keeping appointments); and
(((d))) (c) Assistance with ((obstacles to care, such as
lack of)) transportation((; and
(e) Case management services, for families who do not cooperate with the training(s) in this subsection.
(3) Families who do not cooperate with the training(s) in subsection (2) of this section may be disqualified from the ABCD program. The client remains eligible for MAA dental coverage as described in this chapter.
(4) The)), interpreter services, and other issues related to dental services.
(3) Dentists must be certified through the continuing
education program in the University of Washington School of
Pediatric Dentistry(('s continuing education program certifies
dental providers)) to furnish ABCD program services.
(((5) MAA)) (4) The department pays enhanced fees to
ABCD-certified participating providers for furnishing ABCD
program services. ((In addition to services provided under
MAA's dental care program, the ABCD program provides family
oral health education, which is allowed twice per year, per
family, and must include)) ABCD program services include, when
appropriate:
(a) ((Risk assessment;
(b))) Family oral health ((instruction/training;
(c) Dietary counseling;
(d) Fluoride supplements, if appropriate; and
(e) Documentation in)) education. An oral health education visit:
(i) Must have a duration of at least twenty minutes for each visit;
(ii) Is limited to one visit per day per family, up to two visits per calendar year; and
(iii) Must include all of the following:
(A) "Lift lip" training;
(B) Oral hygiene training;
(C) Risk assessment for early childhood caries;
(D) Dietary counseling;
(E) Topical application of gel or varnish;
(F) Discussion of fluoride supplements; and
(G) Documentation in the client's file or the client's designated adult member's (family member or other responsible adult) file to record the activities provided and duration of the oral education visit.
(b) Comprehensive and periodic oral evaluation, up to two visits per client, per calendar year;
(c) Amalgam and resin restorations on primary teeth, as specified in current department-published documents;
(d) Therapeutic pulpotomy;
(e) Prefabricated stainless steel crowns on primary teeth, as specified in current department-published documents;
(f) Resin-based composite crowns on anterior primary teeth; and
(g) Other dental-related services, as specified in current department-published documents.
(5) The client's file must show documentation of the ABCD program services provided.
[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and .225. 02-11-136, § 388-535-1245, filed 5/21/02, effective 6/21/02.]
The following sections of the Washington Administrative Code are repealed:
| WAC 388-535-1200 | Dental-related services requiring prior authorization -- Children. |
| WAC 388-535-1230 | Crowns for children. |
| WAC 388-535-1240 | Dentures, partial dentures, and overdentures for children. |