WSR 23-24-099
PERMANENT RULES
HEALTH CARE AUTHORITY
[Filed December 6, 2023, 9:26 a.m., effective January 6, 2024]
Effective Date of Rule: Thirty-one days after filing.
Purpose: The health care authority (agency) held a public hearing on September 26, 2023, on WAC 182-535A-0040 under WSR 23-17-086 to make the requirements for "case study" less restrictive in subsection (5)(c). The agency removed "when done in conjunction with limited or comprehensive treatment only" and replaced it with "when done in conjunction with orthodontic treatment."
After the public hearing, the agency recognized that another revision to this section was necessary to make the language less restrictive in who must perform treatment and follow-up care. A supplemental notice was filed on October 25, 2023, under WSR 23-22-055 with a public hearing held on December 5, 2023. The agency revised the language for who can provide treatment and follow-up care to read "by a provider who is part of a craniofacial team that includes, but is not limited to, a general or pediatric dentist, orthodontist, and a maxillofacial surgeon or specialist." The agency removed "only by an orthodontist or agency-recognized craniofacial team."
Citation of Rules Affected by this Order: Amending WAC 182-535A-0040.
Adopted under notice filed as WSR 23-22-055 on October 25, 2023.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 1, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: December 6, 2023.
Wendy Barcus
Rules Coordinator
OTS-4725.2
AMENDATORY SECTION(Amending WSR 23-08-009, filed 3/23/23, effective 4/23/23)
WAC 182-535A-0040Orthodontic treatment and orthodontic-related services—Covered, noncovered, and limitations to coverage.
Orthodontic treatment and orthodontic-related services require prior authorization.
(1) The medicaid agency covers orthodontic treatment and orthodontic-related services for a client who has one of the medical conditions listed in (a) and (b) of this subsection. Treatment and follow-up care must be performed ((only by an orthodontist or agency-recognized craniofacial team))by a provider who is part of a craniofacial team that includes, but is not limited to, a general or pediatric dentist, orthodontist, and an oral maxillofacial surgeon or specialist.
(a) Cleft lip and palate, cleft palate, or cleft lip.
(b) The following craniofacial anomalies including, but not limited to:
(i) Hemifacial microsomia;
(ii) Craniosynostosis syndromes;
(iii) Cleidocranial dental dysplasia;
(iv) Arthrogryposis;
(v) Marfan syndrome;
(vi) Treacher Collins syndrome;
(vii) Ectodermal dysplasia; or
(viii) Achondroplasia.
(2) The agency authorizes orthodontic treatment and orthodontic-related services when the following criteria are met:
(a) Severe malocclusions with a Washington Modified Handicapping Labiolingual Deviation (HLD) Index Score of 25 or higher as determined by the agency;
(b) The client has established caries control; and
(c) The client has established plaque control.
(3) The agency covers orthodontic treatment for dental malocclusions other than those listed in subsections (1) and (2) of this section on a case-by-case basis when the agency determines medical necessity based on documentation submitted by the provider.
(4) The agency does not cover the following orthodontic treatment or orthodontic-related services:
(a) Orthodontic treatment for cosmetic purposes;
(b) Orthodontic treatment that is not medically necessary;
(c) Orthodontic treatment provided out-of-state, except as stated in WAC 182-501-0180 (see also WAC 182-501-0175 for medical care provided in bordering cities); or
(d) Orthodontic treatment and orthodontic-related services that do not meet the requirements of this section or other applicable WAC.
(5) The agency covers the following orthodontic treatment and orthodontic-related services:
(a) Limited orthodontic treatment.
(b) Comprehensive full orthodontic treatment on adolescent dentition.
(c) A case study when done in conjunction with ((limited or comprehensive)) orthodontic treatment ((only)).
(d) Other orthodontic treatment subject to review for medical necessity as determined by the agency.
(6) The agency covers the following orthodontic-related services:
(a) Clinical oral evaluations according to WAC 182-535-1080.
(b) Cephalometric films that are of diagnostic quality, dated, and labeled with the client's name.
(c) Orthodontic appliance removal as a stand-alone service only when:
(i) The client's appliance was placed by a different provider or dental clinic; and
(ii) The provider has not furnished any other orthodontic treatment or orthodontic-related services to the client.
(7) The treatment must meet industry standards and correct the medical issue. If treatment is discontinued prior to completion, or treatment objectives are not achieved, the provider must:
(a) Document in the client's record why treatment was discontinued or not completed, or why treatment goals were not achieved.
(b) Notify the agency by submitting the Orthodontic Discontinuation of Service form (HCA 13-0039).
(8) The agency evaluates a request for orthodontic treatment or orthodontic-related services:
(a) That are in excess of the limitations or restrictions listed in this section, according to WAC 182-501-0169; and
(b) That are listed as noncovered according to WAC 182-501-0160.
(9) The agency reviews requests for orthodontic treatment or orthodontic-related services for clients who are eligible for services under the EPSDT program according to the provisions of WAC 182-534-0100.