HEALTH CARE AUTHORITY
[Filed December 17, 2018, 10:25 a.m.]
Preproposal statement of inquiry was filed as WSR 18-20-066.
Title of Rule and Other Identifying Information: WAC 182-535-1066 Dental-related services—Medical care services clients (formerly general assistance (GA)) and 182-535-1094 Dental-related services—Covered—Oral and maxillofacial surgery services.
Hearing Location(s): On January 22, 2019, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504. Metered public parking is available street side around building. A map is available at https://www.hca.wa.gov/assets/program/Driving-parking-checkin-instructions.pdf or directions can be obtained by calling 360-725-1000.
Date of Intended Adoption: Not sooner than January 23, 2019.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email email@example.com, fax 360-586-9727, by January 22, 2019.
Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, telecommunication relay services 711, email firstname.lastname@example.org, by January 18, 2019.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is revising this section to reflect changes in covered benefits, and to remove certain authorization requirements to expedite claims processing and the delivery of timely services.
Reasons Supporting Proposal: See purpose.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Michael Williams, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1346; Implementation and Enforcement: Pixie Needham, P.O. Box 45502, Olympia, WA 98504-2716, 360-725-9967.
A school district fiscal impact statement is not required under RCW 28A.305.135
A cost-benefit analysis is not required under RCW 34.05.328
. RCW 34.05.328
does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.
The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The revisions to this rule do not impose additional compliance costs or requirements on providers.
December 17, 2018
AMENDATORY SECTION(Amending WSR 17-20-097, filed 10/3/17, effective 11/3/17)
WAC 182-535-1066Dental-related services—Medical care services clients (((formerly general assistance (GA)))).
(1) The medicaid agency covers the following dental-related services for a medical care services client under WAC 182-501-0060 when the services are provided by a dentist to assess, diagnose, and treat pain, infection, or trauma of the mouth, jaw, or teeth, including treatment of postsurgical complications, such as dry socket:
(a) Limited oral evaluation;
(b) Periapical or bitewing radiographs (X-rays) that are medically necessary to diagnose only the client's chief complaint;
(c) Palliative treatment to relieve dental pain or infection;
(d) Pulpal debridement to relieve dental pain or infection; and
(e) Tooth extraction.
(2) ((Tooth extractions require prior authorization when:
(a) The extraction of a tooth or teeth results in the client becoming edentulous in the maxillary arch or mandibular arch; or
(b) A full mouth extraction is necessary because of radiation therapy for cancer of the head and neck.
(3))) Each dental-related procedure described under this section is subject to the coverage limitations listed in this chapter.
AMENDATORY SECTION(Amending WSR 17-20-097, filed 10/3/17, effective 11/3/17)
WAC 182-535-1094Dental-related services—Covered—Oral and maxillofacial surgery services.
Clients described in WAC 182-535-1060 are eligible to receive the oral and maxillofacial surgery services listed in this section, subject to the coverage limitations, restrictions, and client-age requirements identified for a specific service.
(1) Oral and maxillofacial surgery services. The medicaid agency:
(a) Requires enrolled providers who do not meet the conditions in WAC 182-535-1070(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 182-535-1070(3) to bill claims using current procedural terminology (CPT) codes unless the procedure is specifically listed in the agency's current published billing guide 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 age eight and younger;
(ii) Clients age nine through twenty only on a case-by-case basis and when the site-of-service is prior authorized by the agency; and
(iii) Clients any age of the developmental disabilities administration of the department of social and health services (DSHS).
(d) For site-of-service and oral surgery CPT codes that require prior authorization, the agency requires the dental provider to submit current records (within the past twelve months), including:
(i) Documentation used to determine medical appropriateness;
(ii) Cephalometric films;
(iii) Radiographs (X-rays);
(iv) Photographs; and
(v) Written narrative/letter of medical necessity, including proposed billing codes.
(e) Requires the client's dental record to include supporting documentation for each type of extraction or any other surgical procedure billed to the agency. 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 and complete description of each service performed beyond surgical extraction or beyond code definition;
(vi) A copy of the post-operative instructions; and
(vii) A copy of all pre- and post-operative prescriptions.
(f) Covers simple and surgical extractions. ((Authorization is required for the following:
(i) Surgical extractions of four or more teeth per arch over a six-month period, resulting in the client becoming edentulous in the maxillary arch or mandibular arch;
(ii) Simple extractions of four or more teeth per arch over a six-month period, resulting in the client becoming edentulous in the maxillary arch or mandibular arch; or
(iii) Tooth number is not able to be determined.))
(g) Covers unusual, complicated surgical extractions with prior authorization.
(h) Covers tooth reimplantation/stabilization of accidentally evulsed or displaced teeth.
(i) Covers surgical extraction of unerupted teeth for clients.
(j) Covers debridement of a granuloma or cyst that is five millimeters or greater in diameter. The agency includes debridement of a granuloma or cyst that is less than five millimeters as part of the global fee for the extraction.
(k) Covers ((the following without prior authorization:
(i)))biopsy of soft oral tissue((;
(ii))), brush biopsy((; and
(iii))), and surgical excision of soft tissue lesions. (((l) Requires providers to keep all biopsy reports or findings in the client's dental record.
(m) Covers the following with prior authorization (photos or radiographs, as appropriate, must be submitted to the agency with the prior authorization request):
(i) Alveoloplasty on a case-by-case basis.
(ii)))Providers must keep all biopsy reports or findings in the client's dental record.
(l) Covers only the following excisions of bone tissue in conjunction with placement of complete or partial dentures:
(((A)))(i) Removal of lateral exostosis;
(((B)))(ii) Removal of torus palatinus or torus mandibularis; ((and
(C)))(iii) Surgical reduction of osseous tuberosity.
(((iii) Surgical access of unerupted teeth for clients age twenty and younger.))
(3)Surgical incisions. The agency covers the following surgical incision-related services:
(a) Uncomplicated intraoral and extraoral soft tissue incision and drainage of abscess. The agency does not cover this service when combined with an extraction or root canal treatment. Documentation supporting the medical necessity must be in the client's record.
(b) Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue. Documentation supporting the medical necessity for the service must be in the client's record.
(c) Frenuloplasty/frenulectomy for clients age six and younger without prior authorization.
(d) Frenuloplasty/frenulectomy for clients age seven through twelve only on a case-by-case basis and when prior authorized. Photos must be submitted to the agency with the prior authorization request. Documentation supporting the medical necessity for the service must be in the client's record.
(e) Surgical access of unerupted teeth for clients age twenty and younger, with prior authorization.
(((3)))(4)Occlusal orthotic devices. (Refer to WAC 182-535-1098 (4)(c) for occlusal guard coverage and limitations on coverage.) The agency covers:
(a) Occlusal orthotic devices for clients age 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.