WSR 23-08-009
PERMANENT RULES
HEALTH CARE AUTHORITY
[Filed March 23, 2023, 7:54 a.m., effective April 23, 2023]
Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency amended this rule to remove subsection (4)(e) to be less restrictive for providers using removable appliances as part of orthodontic treatment. The agency also removed "with alveolar process involvement" from subsection (1)(a) to eliminate limiting clients who have a cleft lip to shoe [those] with an alveolar process involvement.
Citation of Rules Affected by this Order: Amending WAC 182-535A-0040.
Adopted under notice filed as WSR 23-05-079 on February 14, 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Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: March 23, 2023.
Wendy Barcus
Rules Coordinator
OTS-4305.1
AMENDATORY SECTION(Amending WSR 21-18-006, filed 8/18/21, effective 1/1/22)
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.
(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))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((; or
(e) Removable appliances as part of limited or comprehensive orthodontic treatment)).
(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.