WSR 02-01-050

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed December 11, 2001, 3:42 p.m. ]

Date of Adoption: December 5, 2001.

Purpose: The department originally intended to amend WAC 388-535-1250 Orthodontic coverage for DSHS children, in order to clarify and update the policy. As amendments to this section were being developed, the department decided to establish a separate chapter for this program (chapter 388-535A WAC) so the distinction between the dental and orthodontic programs will be clear. The new chapter accurately reflects current program policy.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-535-1250 Orthodontic coverage for DSHS children.

Statutory Authority for Adoption: 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.

Adopted under notice filed as WSR 01-20-110 on October 3, 2001.

Changes Other than Editing from Proposed to Adopted Version: Changes follow; additions are indicated by underlining and deletions are indicated by strikethrough:

WAC 388-535A-0040 (1)(v) Medical conditions as indicated on the Washington Modified Handicapping Labiolingual Deviation (HLD) Index that result in a score of twenty-five or higher. MAA reviews all requests for treatment for conditions that result in a score of less than twenty-five based on medical necessity on a case-by-case basis.

WAC 388-535A-0040(2) MAA may cover requests for medically necessary orthodontic treatment for dental malocclusions, other than those listed in subsection (1) of this section, when MAA determines that the treatment is medically necessary. that result in severe dental functional impairment. MAA covers these cases: (a) On a case-by-case basis; (b) Based on medical necessity; and (c) Based on a score of twenty-five or higher on the Washington Modified Handicapping Labiolingual Deviation (HLD) Index.

WAC 388-535A-0040(6) MAA covers panoramic radiographs (x-rays) once in a three-year period.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 6, Amended 0, Repealed 1.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 6, Amended 0, Repealed 1.

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 6, Amended 0, Repealed 1.
Effective Date of Rule: Thirty-one days after filing.

December 5, 2001

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

2996.4
Chapter 388-535A WAC

ORTHODONTIC SERVICES


NEW SECTION
WAC 388-535A-0010   Definitions for orthodontic services.   The following definitions and those found in WAC 388-500-0005 apply to this chapter. Defined words and phrases are bolded the first time they are used in the text.

"Appliance placement" means the application of orthodontic attachments to the teeth for the purpose of correcting dentofacial abnormalities.

"Cleft" means an opening or fissure involving the dentition and supporting structures especially one occurring in utero. These can be:

(1) Cleft lip;

(2) Cleft palate (involving the roof of the mouth); or

(3) Facial clefts (e.g., macrostomia).

"Comprehensive full orthodontic treatment" means utilizing fixed orthodontic appliances for treatment of the permanent dentition leading to the improvement of a patient's severe handicapping craniofacial dysfunction and/or dentofacial deformity, including anatomical and functional relationships.

"Craniofacial anomalies" means abnormalities of the head and face, either congenital or acquired, involving disruption of the dentition and supporting structures.

"Craniofacial team" means a department of health- and medical assistance administration-recognized cleft palate/maxillofacial team or an American Cleft Palate Association-certified craniofacial team. These teams are responsible for management (review, evaluation, and approval) of patients with cleft palate craniofacial anomalies to provide integrated case management, to promote parent-professional partnership, and make appropriate referrals to implement and coordinate treatment plans.

"Dental dysplasia" means an abnormality in the development of the teeth.

"EPSDT" means the department's early and periodic screening, diagnosis, and treatment program for clients twenty years of age and younger as described in chapter 388-534 WAC.

"Hemifacial microsomia" means a developmental condition involving the first and second brachial arch. This creates an abnormality of the upper and lower jaw, ear, and associated structures (half or part of the face appears smaller sized).

"Interceptive orthodontic treatment" means procedures to lessen the severity or future effects of a malformation and to affect or eliminate the cause. It is an extension of preventive orthodontics that may include localized tooth movement. Such treatment may occur in the primary or transitional dentition and may include such procedures as the redirection of ectopically erupting teeth, correction of isolated dental cross-bite, or recovery of recent minor space loss where overall space is adequate.

"Limited transitional orthodontic treatment" means orthodontic treatment with a limited objective, not involving the entire dentition. It may be directed only at the existing problem, or at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy.

"Malocclusion" means the abnormal contact between the upper and lower teeth that interferes with the highest efficiency during the movements of the jaw that are essential to chewing.

"Maxillofacial" means relating to the jaws and face.

"Occlusion" means the relation of the upper and lower teeth when in functional contact during jaw movement.

"Orthodontics" means treatment involving the use of any appliance, in or out of the mouth, removable or fixed, or any surgical procedure designed to redirect teeth and surrounding tissues.

"Orthodontist" means a dentist who specializes in orthodontics, who is a graduate of a postgraduate program in orthodontics that is accredited by the American Dental Association, and who meets the licensure requirements of the department of health.

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NEW SECTION
WAC 388-535A-0020   Eligibility for orthodontic services.   (1) Subject to the limits of this chapter, the medical assistance administration (MAA) covers medically necessary orthodontic treatment for severe handicapping malocclusions, craniofacial anomalies, or cleft lip or palate for children only, as follows:

(a) Clients in the categorically needy program (CN) receive orthodontic services through age twenty;

(b) Clients in the children's health program receive orthodontic services through age eighteen; and

(c) Clients in the EPSDT program receive orthodontic services through age twenty.

(2) MAA does not cover orthodontic services for adults.

(3) Eligible clients in department-designated border areas may receive the same orthodontic services as if provided in-state.

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NEW SECTION
WAC 388-535A-0030   Providers of orthodontic services.   With prior approval from MAA, except as indicated under WAC 388-535A-0050, the following providers may furnish and be reimbursed for covered comprehensive full orthodontic treatment, interceptive orthodontic treatment (see WAC 388-535A-0060(7)), or limited orthodontic treatment (see WAC 388-535A-0060(8)), furnished to MAA clients:

(1) Dentists who specialize in orthodontics;

(2) Pediatric dentists who provide MAA-approved orthodontic services;

(3) General dentists who provide MAA-approved orthodontic services; and

(4) Oral surgeons who provide MAA-approved orthodontic services.

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NEW SECTION
WAC 388-535A-0040   Orthodontic coverage.   (1) MAA covers medically necessary orthodontic treatment for severe handicapping malocclusions, craniofacial anomalies, or cleft lip or palate when the client meets the eligibility requirements in WAC 388-535A-0020 and the medical conditions in this section. The client must have one of the following:

(a) Cleft (lip or palate), or craniofacial anomaly when the client is treated by and receives follow-up care by a department-recognized cleft palate or craniofacial team for:

(i) Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement;

(ii) Craniofacial anomalies, including but not limited to:

(A) Hemifacial microsomia;

(B) Craniosynostosis syndromes;

(C) Cleidocranial dental dysplasia;

(D) Arthrogryposis; or

(E) Marfan syndrome.

(iii) Other medical conditions with significant facial growth impact (e.g., juvenile rheumatoid arthritis (JRA)); or

(iv) Post traumatic, post radiation, or post burn jaw deformity.

(b) Other severe handicapping malocclusions, including one or more of the following:

(i) Deep impinging overbite when lower incisors are destroying the soft tissues of the palate;

(ii) Crossbite of individual anterior teeth when destruction of the soft tissue is present;

(iii) Severe traumatic malocclusion (e.g., loss of a premaxilla segment by burns or by accident, the result of osteomyelitis, or other gross pathology);

(iv) Overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5mm with reported masticatory and speech difficulties; or

(v) Medical conditions as indicated on the Washington Modified Handicapping Labiolingual Deviation (HLD) Index Score that result in a score of twenty-five or higher. MAA reviews all requests for treatment for conditions that result in a score of less then twenty-five, based on medical necessity on a case-by-case basis.

(2) MAA may cover requests for orthodontic treatment for dental malocclusions, other than those listed in subsection (1) of this section when MAA determines that the treatment is medically necessary.

(3) MAA reviews requests for orthodontic treatment for children who are eligible for services under the EPSDT program according to the provisions of WAC 388-534-0100.

(4) MAA covers orthodontic appliance removal for a client whose appliance was placed by a provider not participating with MAA, or whose payment MAA did not cover.

(5) MAA does not cover lost or broken orthodontic appliances.

(6) MAA covers panoramic radiographs (x-rays) once in a three-year period.

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NEW SECTION
WAC 388-535A-0050   Authorization, prior authorization, and expedited prior authorization for orthodontic services.   (1) When MAA authorizes a service, that authorization indicates only that the specific service is medically necessary; it is not a guarantee of payment. The client must be eligible for the covered service at the time the service is provided.

(2) MAA does not require prior authorization for orthodontic treatment of a client with cleft lip, cleft palate, or craniofacial anomaly when the client is:

(a) Eligible under WAC 388-535A-0020; and

(b) Being treated by a department-recognized cleft palate or craniofacial team.

(3) MAA requires prior authorization for orthodontic treatment of:

(a) Severe handicapping malocclusions;

(b) Dental malocclusions that result in severe dental functional impairment;

(c) Those cases that result in a score less than thirty on the Washington Modified HLD Index Scale; and

(d) Services provided per WAC 388-535A-0030.

(4) MAA allows orthodontists to use expedited prior authorization (EPA) for those cases that score thirty or more on the Washington Modified HLD Index Scale. The EPA process is designed to eliminate the need for telephone prior authorization for selected procedures. The orthodontist must create an authorization number using the process explained in MAA's orthodontic billing instructions. When MAA finds that a provider is using EPA inappropriately, MAA may:

(a) Require the provider to obtain prior authorization from MAA before providing services to any client; or

(b) Take one or more of the actions in WAC 388-502-0230(3).

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NEW SECTION
WAC 388-535A-0060   Reimbursement for orthodontic services.   (1) MAA considers that a provider who furnishes covered orthodontic services to an eligible client has accepted MAA's rates and fees.

(2) Payment for orthodontic services is based on MAA's schedule of maximum allowances; fees listed in the fee schedule are the maximum allowable fees.

(3) MAA uses state-assigned procedure codes to identify covered orthodontic services.

(4) MAA does not cover out-of-state orthodontic treatment.

(5) Orthodontic providers who are in department-designated border areas must:

(a) Meet the licensure requirements of their state; and

(b) Meet the same criteria for payment as in-state providers, including the requirements to contract with MAA.

(6) MAA reimburses for interceptive orthodontic treatment for cleft palate or craniofacial anomaly per WAC 388-535A-0050.

(7) With the exception of the conditions listed in subsection (6) of this section, MAA reimburses for interceptive orthodontic treatment once per client's lifetime for clients with severe handicapping malocclusions.

(8) MAA reimburses for limited transitional orthodontic treatment for a maximum of one year from original appliance placement. Follow up treatment is allowed in three-month increments, beginning three months after the initial placement.

(9) MAA reimburses for comprehensive full orthodontic treatment up to a maximum of two years from original appliance placement. Six follow up treatments are allowed in three-month increments, beginning six months after the initial placement.

(10) If the client's eligibility for orthodontic treatment under WAC 388-535A-0020 ends before the conclusion of the orthodontic treatment, payment for any remaining treatment is the individual's responsibility; MAA does not reimburse for these services.

(11) The client is responsible for payment of any orthodontic service or treatment received during any period of ineligibility, even if the treatment was started when the client was eligible; MAA does not reimburse for these services.

(12) The client is responsible for paying for services when the client has not disclosed coverage to the provider, per WAC 388-502-0160 and 388-501-0200; MAA does not reimburse in these situations.

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2997.1
REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 388-535-1250 Orthodontic coverage for DSHS children.

Washington State Code Reviser's Office