PDFWAC 182-535A-0040

Orthodontic treatment and orthodontic-related services—Covered, noncovered, and limitations to coverage.

Coverage and authorization of covered services is subject to the requirements and limitations in this chapter and other applicable WAC.
(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.
(a) Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement.
(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 twenty-five 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 may cover orthodontic treatment for dental malocclusions other than those listed in subsections (1) and (2) of this section on a case-by-case basis and when prior authorized. 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 (as defined in WAC 182-500-0070);
(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);
(d) Orthodontic treatment and orthodontic-related services that do not meet the requirements of this section or other applicable WAC; or
(e) Case studies that do not include a definitive orthodontic treatment plan.
(5) The agency covers the following orthodontic treatment and orthodontic-related services with prior authorization when medically necessary:
(a) Interceptive orthodontic treatment.
(b) Limited orthodontic treatment. The agency may approve limited orthodontic treatment for treatment of a single impacted tooth.
(c) Comprehensive full orthodontic treatment on adolescent dentition (see subsection (8)(a) of this section for information on limitation extensions).
(d) Case study.
(e) Other orthodontic treatment subject to review for medical necessity as determined by the agency.
(6) The agency covers the following orthodontic-related services with prior authorization when medically necessary:
(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) Replacement retainer.
(d) 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) Keep clear documentation in the client's record explaining why treatment was discontinued or not completed, or why treatment goals were not achieved.
(b) Notify the agency.
(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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-11-028, § 182-535A-0040, filed 5/7/19, effective 7/1/19; WSR 17-20-097, § 182-535A-0040, filed 10/3/17, effective 11/3/17; WSR 16-10-064, § 182-535A-0040, filed 5/2/16, effective 6/2/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0040, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0040, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0040, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-535A-0040, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0040, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0040, filed 12/11/01, effective 1/11/02.]