Clients described in WAC 182-535-1060 are eligible to receive the dental-related endodontic services listed in this section, subject to coverage limitations, restrictions, and client age requirements identified for a specific service.

(1) Pulp capping. The medicaid agency considers pulp capping to be included in the payment for the restoration.

(2) Pulpotomy. The agency covers:

(a) Therapeutic pulpotomy on primary teeth only for clients age twenty and younger.

(b) Pulpal debridement on permanent teeth only, excluding teeth one, sixteen, seventeen, and thirty-two. The agency does not pay for pulpal debridement when performed with palliative treatment of dental pain or when performed on the same day as endodontic treatment.

(3) Endodontic treatment on primary teeth. The agency covers endodontic treatment with resorbable material for primary teeth, if the entire root is present at treatment.

(4) Endodontic treatment on permanent teeth. The agency:

(a) Covers endodontic treatment for permanent anterior teeth for all clients.

(b) Covers endodontic treatment for permanent bicuspid and molar teeth, excluding teeth one, sixteen, seventeen, and thirty-two for clients age twenty and younger.

(i) Pulpectomy when part of root canal therapy;

(ii) All procedures necessary to complete treatment; and

(iii) All intra-operative and final evaluation radiographs (X-rays) for the endodontic procedure.

(d) Pays separately for the following services that are related to the endodontic treatment:

(i) Initial diagnostic evaluation;

(ii) Initial diagnostic radiographs; and

(iii) Post treatment evaluation radiographs if taken at least three months after treatment.

(5) Endodontic retreatment on permanent anterior teeth. The agency:

(a) Covers endodontic retreatment for clients age twenty and younger when prior authorized.

(b) Covers endodontic retreatment of permanent anterior teeth for clients twenty-one years of age and older when prior authorized.

(i) The removal of post(s), pin(s), old root canal filling material, and all procedures necessary to prepare the canals;

(ii) Placement of new filling material; and

(iii) Retreatment for permanent anterior, bicuspid, and molar teeth, excluding teeth one, sixteen, seventeen, and thirty-two.

(d) Pays separately for the following services that are related to the endodontic retreatment:

(i) Initial diagnostic evaluation;

(ii) Initial diagnostic radiographs; and

(iii) Post treatment evaluation radiographs if taken at least three months after treatment.

(e) Does not pay for endodontic retreatment when provided by the original treating provider or clinic unless prior authorized by the agency.

(6) Apexification/apicoectomy. The agency covers:

(a) Apexification for apical closures for anterior permanent teeth only. Apexification is limited to the initial visit and three interim treatment visits per tooth and is limited to clients age twenty and younger.

(b) Apicoectomy and a retrograde fill for anterior teeth only for clients age twenty and younger.

PDFWAC 182-535-1086

Dental-related services—Covered—Endodontic services.