PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: The new and amended sections clarify and update policies for dental-related services for clients age twenty-one and older; ensure that department policies are applied correctly and equitably; replace the terms "medical assistance administration" and "MAA" with "the department"; update policy regarding prior authorization requirements; clarify policy on covered versus noncovered benefits; clarify additional benefits and limitations associated with those services for clients age twenty-one and older; and repeal WAC 388-535-1270 and 388-535-1290 and incorporate updated policy into new sections. Clients and dental providers will be able to identify the requirements and criteria that must be met in order to obtain covered dental-related services.
Citation of Existing Rules Affected by this Order: Repealing WAC 388-535-1270 and 388-535-1290; and amending WAC 388-535-1050, 388-535-1065, 388-535-1255, and 388-535-1280.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.500, 74.09.520.
Adopted under notice filed as WSR 07-02-088 (part 1 of 4), 07-02-089 (part 2 of 4), 07-02-090 (part 3 of 4), and 07-02-091 (part 4 of 4) on January 3, 2007.
Changes Other than Editing from Proposed to Adopted Version: Amended Sections:
WAC 388-535-1247 (1) Subject to coverage limitations,
Tthe department pays for ...when the services and procedures:
...(d) Are documented in the client's record in accordance with
chapter 388-502 WAC;
(d) (e) Are within prevailing standard of care accepted
dental or medical practice standards;
(e) (f) Are consistent...;
(f) (g) Are reasonable...; and
(g) (h) Are listed...
WAC 388-535-1266 (1)(a) Requires prior authorization...In
addition, the department requires the dental provider to
submit all the following: (i) Submit: (A) Appropriate and
diagnostic radiographs of all remaining teeth; (ii) (B) A
dental record that identifies: (A) (I) All missing teeth for
both arches; (B) (II) Teeth that are to be extracted; and (C)
(III) Dental and periodontal services completed on all
remaining teeth. (iii) (C) A prescription written ...
(ii) Obtain a signed agreement of acceptance from the client at the conclusion of the final denture try-in for a department authorized complete denture or a cast-metal denture described in this section. If the client abandons the complete denture or the cast-metal partial denture after signing the agreement of acceptance, the department will deny subsequent requests for the same type dental prosthesis if the request occurs prior to the dates specified in this section. A copy of the signed agreement that documents the client's acceptance of the dental prosthesis must be submitted to the department's dental prior authorization section before the department pays the claim.
WAC 388-535-1267 (1)(h) Covers alveoloplasty: (i) Only
only when three or more teeth are extracted per arch.; and
(ii) That is not performed in conjunction with extractions
only on a case-by-case basis and when prior authorized.
A final cost-benefit analysis is available by contacting Dr. John Davis, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1748, fax (360) 568-1590, e-mail davisjs@dshs.wa.gov.
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 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 9, Amended 4, Repealed 2.
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 9, Amended 4, Repealed 2.
Date Adopted: February 27, 2007.
Robin Arnold-Williams
Secretary
3822.4"Access to baby and child dentistry (ABCD)" is a program to increase access to dental services in targeted areas for Medicaid eligible infants, toddlers, and preschoolers up through the age of five. See WAC 388-535-1300 for specific information.
"American Dental Association (ADA)" is a national organization for dental professionals and dental societies.
(("Adult" for the general purposes of the medical
assistance administration's (MAA) dental program, means a
client twenty-one years of age or older (MAA's payment
structure changes at age nineteen, which affects specific
program services provided to adults or children).))
"Anterior" ((means teeth)) refers to teeth (maxillary and
mandibular incisors and canines) and tissue in the front of
the mouth. Permanent maxillary anterior teeth include teeth
six, seven, eight, nine, ten, and eleven. Permanent
mandibular anterior teeth include teeth twenty-two,
twenty-three, twenty-four, twenty-five, twenty-six, and
twenty-seven. Primary maxillary anterior teeth include teeth
C, D, E, F, G, and H. Primary mandibular anterior teeth
include teeth M, N, O, P, Q, and R.
(((1) "Mandibular anterior teeth" - incisors and canines:
Permanent teeth twenty-two, twenty-three, twenty-four,
twenty-five, twenty-six, and twenty-seven; and primary teeth
M, N, O, P, Q, and R.
(2) "Maxillary anterior teeth" - incisors and canines: Permanent teeth six, seven, eight, nine, ten, and eleven; and primary teeth C, D, E, G, and H.))
"Asymptomatic" means having or producing no symptoms.
"Base metal" means dental alloy containing little or no precious metals.
"Behavior management" means using the assistance of one
additional dental professional staff to manage the behavior of
((a developmentally disabled client or)) a client ((age
eighteen or younger)) to facilitate the delivery of dental
treatment.
"By report" - a method of reimbursement in which ((MAA))
the department determines the amount it will pay for a service
when the rate for that service is not included in ((MAA's))
the department's published fee schedules. Upon request the
provider must submit a "report" which describes the nature,
extent, time, effort and/or equipment necessary to deliver the
service.
"Caries" means carious lesions or tooth decay through the enamel or decay of the root surface.
(("Child" for the general purposes of the medical
assistance administration's (MAA) dental program, means a
client twenty years of age or younger. (MAA's payment
structure changes at age nineteen, which affects specific
program services provided to children or adults.)))
"Comprehensive oral evaluation" means a thorough
evaluation and ((recording)) documentation of a client's
dental and medical history to include extra-oral and
intra-oral hard and soft tissues, dental caries, missing or
unerupted teeth, restorations, occlusal relationships,
periodontal conditions (including periodontal charting), hard
and soft tissue anomalies, and oral cancer screening.
"Conscious sedation" is a drug-induced depression of
consciousness during which a client((s)) responds purposefully
to verbal commands, either alone or accompanied by light
tactile stimulation. No interventions are required to
maintain a patent airway, spontaneous ventilation is adequate,
and cardiovascular function is maintained.
"Core buildup" refers to building up of clinical crowns, including pins.
"Coronal" is the portion of a tooth that is covered by
enamel((, and is separated from the root or roots by a
slightly constricted region, known as the cemento-enamel
junction)).
"Coronal polishing" is a mechanical procedure limited to the removal of plaque and stain from exposed tooth surfaces.
"Crown" means a restoration covering or replacing ((the
major)) part((,)) or the whole ((of, the)) clinical crown of a
tooth.
"Current dental terminology (CDT)" is a systematic listing of descriptive terms and identifying codes for reporting dental services and procedures performed by dental practitioners. CDT is published by the Council on Dental Benefit Programs of the American Dental Association (ADA).
"Current procedural terminology (CPT)" ((means a
description of medical procedures and is available from the
American Medical Association of Chicago, Illinois)) is a
systematic listing of descriptive terms and identifying codes
for reporting medical services, procedures, and interventions
performed by physicians and other practitioners who provide
physician-related services. CPT is copyrighted and published
annually by the American Medical Association (AMA).
"Decay" is a term for caries or carious lesions and means decomposition of tooth structure.
"Deep sedation" is a drug-induced depression of consciousness during which a client cannot be easily aroused, ventilatory function may be impaired, but the client responds to repeated or painful stimulation.
"Dental general anesthesia" see "general anesthesia."
"Dentures" means an artificial replacement for natural teeth and adjacent tissues, and includes complete dentures, immediate dentures, overdentures, and partial dentures.
"Denturist" means a person licensed under chapter 18.30 RCW to make, construct, alter, reproduce, or repair a denture.
"Endodontic" means ((disease and injuries to the pulp
requiring root canal therapy and related follow-up)) the
etiology, diagnosis, prevention and treatment of diseases and
injuries of the pulp and associated periradicular conditions.
"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.
"Extraction" see "simple extraction" and "surgical extraction."
"Flowable composite ((resin))" is a ((low viscosity
resin)) diluted resin-based composite dental restorative
material that is used in cervical ((lesions)) restorations and
((other)) small, low stress bearing occlusal restorations.
"Fluoride varnish, rinse, foam or gel" ((means)) is a
substance containing dental fluoride((,)) which is applied to
teeth.
"General anesthesia" is a drug-induced loss of
consciousness during which a client((s are)) is not arousable
even by painful stimulation. The ability to independently
maintain ventilatory function is often impaired. Clients may
require assistance in maintaining a patent airway, and
positive pressure ventilation may be required because of
depressed spontaneous ventilation or drug-induced depression
of neuromuscular function. Cardiovascular function may be
impaired.
"High noble metal" ((means)) is a dental alloy containing
at least sixty percent pure gold.
"Limited oral evaluation" ((means)) is an evaluation
limited to a specific oral health condition or problem. Typically a client receiving this type of evaluation has a
dental emergency, such as trauma or acute infection.
"Limited visual oral assessment" ((means a screening of
the hard and soft tissues in the mouth)) is an assessment by a
dentist or dental hygienist to determine the need for fluoride
treatment and/or when triage services are provided in settings
other than dental offices or dental clinics.
"Major bone grafts" ((means)) is a transplant of solid
bone tissue(s).
"Medically necessary" see WAC 388-500-0005.
"Minor bone grafts" ((means)) is a transplant of nonsolid
bone tissue(s), such as powdered bone, buttons, or plugs.
"Noble metal" ((means)) is a dental alloy containing at
least twenty-five percent but less than sixty percent pure
gold.
"Oral evaluation" see "comprehensive oral evaluation."
"Oral hygiene instruction" means instruction for home oral hygiene care, such as tooth brushing techniques or flossing.
"Oral prophylaxis" ((means)) is the ((preventive)) dental
procedure of scaling and polishing which includes removal of
calculus, ((soft deposits,)) plaque, and stains from teeth
((and tooth implants)).
"Partials" or "partial dentures" ((means)) are a
removable prosthetic appliance ((replacing one or more)) that
replaces missing teeth in one arch((, and receiving its
support and retention from both the underlying tissues and
some or all of the remaining teeth)).
"Periodic oral evaluation" ((means)) is an evaluation
performed on a patient of record to determine any changes in
the client's dental or medical status since a previous
comprehensive or periodic evaluation. ((This includes a
periodontal charting at least once per year.))
"Periodontal maintenance" ((means)) is a procedure ((for
clients who have previously been treated for periodontal
disease and starts after completion of active (surgical or
nonsurgical) periodontal therapy. It includes removal of the
supra and subgingival microbial flora and calculus from teeth
and tooth implants)) performed for clients who have previously
been treated for periodontal disease with surgical or
nonsurgical treatment. It includes the removal of
supragingival and subgingival microorganisms and deposits with
hand and mechanical instrumentation, an evaluation of
periodontal conditions, and a complete periodontal charting as
appropriate.
"Periodontal scaling and root planing" ((means
instrumentation of the crown and root surfaces of the teeth or
tooth implants)) is a procedure to remove plaque, calculus,
((microbial flora, and bacterial toxins)) microorganisms, and
rough cementum and dentin from tooth surfaces. This includes
hand and mechanical instrumentation, an evaluation of
periodontal conditions, and a complete periodontal charting as
appropriate.
"Posterior" ((means)) refers to the teeth (maxillary and
mandibular premolars and molars) and tissue towards the back
of the mouth. Permanent maxillary posterior teeth include
teeth one, two, three, four, five, twelve, thirteen, fourteen,
fifteen, and sixteen. Permanent mandibular posterior teeth
include teeth seventeen, eighteen, nineteen, twenty,
twenty-one, twenty-eight, twenty-nine, thirty, thirty-one, and
thirty-two. Primary maxillary posterior teeth include teeth
A, B, I, and J. Primary mandibular posterior teeth include
teeth K, L, S, and T.
(((1) "Mandibular posterior teeth" - molars and
premolars: Permanent teeth seventeen, eighteen, nineteen,
twenty, twenty-one, twenty-eight, twenty-nine, thirty,
thirty-one, and thirty-two; and primary teeth K, L, S, and T.
(2) "Maxillary posterior teeth" - molars and premolars: Permanent teeth one, two, three, four, five, twelve, thirteen, fourteen, fifteen, and sixteen; and primary teeth A, B, I, and J.))
"Proximal" ((means)) is the surface of the tooth near or
next to the adjacent tooth.
"Radiograph" is an image or picture produced on a radiation sensitive film emulsion or digital sensor by exposure to ionizing radiation.
"Reline" means to resurface the tissue side of a denture with new base material or soft tissue conditioner in order to achieve a more accurate fit.
"Root canal" is ((a portion of the pulp cavity inside the
root of a tooth and)) the chamber within the root of the tooth
that contains the pulp.
"Root canal therapy" is the treatment of ((disease and
injuries of)) the pulp and associated periradicular
conditions.
"Root planing" is a procedure to remove ((microbial
flora, bacterial toxins)) plaque, calculus, ((and diseased))
microorganisms, and rough cementum ((or dentin on the root))
and dentin from tooth surfaces ((and pockets, including tooth
implants)). This includes hand and mechanical
instrumentation.
"Scaling" is a procedure to remove plaque, calculus, and
stain deposits from tooth surfaces((, including tooth
implants)).
"Sealant" is a dental material applied to teeth to prevent dental caries.
"Simple extraction" ((means)) is the routine removal of a
tooth ((structure)).
"Standard of care" means what reasonable and prudent practitioners would do in the same or similar circumstances.
"Surgical extraction" ((means)) is the removal of a tooth
((structure with)) by cutting of the gingiva and bone((,
including)). This includes soft tissue extractions, partial
boney extractions, and complete boney extractions.
"Symptomatic" means having symptoms (e.g., pain, swelling, and infection).
"((Tempormandibular)) Temporomandibular joint dysfunction
(TMJ/TMD)" ((means)) is an abnormal functioning of the
((tempormandibular)) temporomandibular joint or other areas
secondary to the dysfunction.
"Therapeutic pulpotomy" ((means)) is the surgical removal
of a portion of the pulp (inner soft tissue of a tooth), to
retain the healthy remaining pulp.
"Usual and customary" means the fee that the provider
usually charges non-Medicaid customers for the same service or
item. This is the maximum amount that the provider may bill
((MAA)) the department.
"Wisdom teeth" ((means)) are the third molars, teeth one,
sixteen, seventeen, and thirty-two.
"Xerostomia" ((means)) is a dryness of the mouth due to
decreased saliva.
[Statutory Authority: RCW 74.04.050, 74.04.057, and 74.09.530. 04-14-100, § 388-535-1050, filed 7/6/04, effective 8/6/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-077, § 388-535-1050, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1050, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090. 01-02-076, § 388-535-1050, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1050, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1050, filed 12/6/95, effective 1/6/96.]
(a) General assistance unemployable (GA-U); and
(b) Alcohol and drug abuse treatment and support act
(ADATSA) (((GA-W))).
(2) The ((medical assistance administration (MAA)))
department covers the following dental-related services
((described and limited in this chapter)) for a client((s))
eligible ((for)) under the GA-U or ((GA-W only when those
services are provided as part of a medical treatment for))
ADATSA program:
(a) ((Apical abscess verified by clinical examination and
radiograph(s), and treated by)) Services provided only as part
of dental treatment for:
(i) Limited oral evaluation;
(ii) Periapical or bite-wing radiographs that are medically necessary to diagnose only the client's chief complaint;
(iii) Palliative treatment (((e.g., open and drain, open
and broach))) to relieve dental pain;
(((ii) Tooth extraction; or
(iii) Root canal therapy for permanent anterior teeth only.
(b) Tooth fractures (limited to extraction).
(c) Total dental extraction prior to and because of radiation therapy for cancer of the mouth))
(iv) Pulpal debridement to relieve dental pain; or
(v) Endodontic (root canal only) treatment for maxillary and mandibular anterior teeth (cuspids and incisors) when prior authorized).
(b) Tooth extraction when at least one of the following apply:
(i) The tooth has a radiograph apical lesion;
(ii) The tooth is endodontically involved, infected, or abcessed;
(iii) The tooth is not restorable; or
(iv) The tooth is not periodontally stable.
(3) Tooth extractions require prior authorization when:
(i) The extraction of a tooth or teeth results in the client becoming edentulous in the maxillary arch or mandibular arch; and
(ii) A full mouth extraction is necessary because of radiation therapy for cancer of the head and neck.
(4) Each dental-related procedure described under this section is subject to the coverage limitations listed in chapter 388-535 WAC for clients through age twenty.
(5) The department does not cover any dental-related services not listed in this section for clients eligible under the GA-U or ADATSA program, including any type of removable prosthesis (denture).
[Statutory Authority: RCW 74.04.050, 74.04.057, and 74.09.530. 04-14-100, § 388-535-1065, filed 7/6/04, effective 8/6/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-077, § 388-535-1065, filed 9/12/03, effective 10/13/03.]
Reviser's note: The spelling error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
NEW SECTION
WAC 388-535-1247
Dental-related services for clients age
twenty-one and older-General.
(1) Subject to coverage
limitations, the department pays for dental-related services
and procedures provided to clients age twenty-one and older
when the services and procedures:
(a) Are within the scope of an eligible client's medical care program;
(b) Are medically necessary as defined in WAC 388-500-0005;
(c) Meet the department's prior authorization requirements, if any;
(d) Are documented in the client's record in accordance with chapter 388-502 WAC;
(e) Are within prevailing standard of care accepted dental or medical practice standards;
(f) Are consistent with a diagnosis of dental disease or condition;
(g) Are reasonable in amount and duration of care, treatment, or service; and
(h) Are listed as covered in the department's published rules, billing instructions and fee schedules.
(2) Clients who are eligible for services through the division of developmental disabilities may receive dental-related services under the provisions of WAC 388-535-1099.
(3) The department evaluates a request for dental-related services:
(a) That are in excess of the dental program's limitations or restrictions, according to WAC 388-501-0169; and
(b) That are listed as noncovered under the provisions in WAC 388-501-0160.
[]
3824.2(a) Within the scope of an eligible client's medical care program;
(b) Medically necessary; and
(c) Within accepted dental or medical practice standards and are:
(i) Consistent with a diagnosis of dental disease or condition; and
(ii) Reasonable in amount and duration of care, treatment, or service.
(2) MAA covers the following dental-related services for eligible adults, subject to the restrictions and limitations in this section and other applicable WAC:
(a) Medically necessary services for the identification of dental problems or the prevention of dental disease, subject to the limitations of this chapter.
(b) A comprehensive oral evaluation once per provider as an initial examination, that must include:
(i) A complete dental and medical history and a general health assessment;
(ii) A complete thorough evaluation of extra-oral and intra-oral hard and soft tissue; and
(iii) The evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, and oral cancer screening.
(c) Periodic oral evaluations once every six months to include a periodontal screening/charting at least once per year. There must be six months between the comprehensive oral evaluation and the first periodic oral evaluation.
(d) Limited oral evaluations only when the provider is not providing prescheduled dental services for the client. The limited oral evaluation must be:
(i) To provide limited or emergent services for a specific dental problem; and/or
(ii) To provide an evaluation for a referral.
(e) Radiographs, as follows:
(i) Intraoral, complete series (including bitewings), allowed only once in a three-year period;
(ii) Panoramic film, allowed only once in a three-year period and only for oral surgical purposes (see subsection (3) of this section for clients of the division of developmental disabilities);
(iii) Periapical radiographs as needed (periapical radiographs and bitewings taken on the same date of service cannot exceed MAA's fee for a complete intraoral series); and
(iv) Bitewings, up to four allowed every twelve months.
(f) Fluoride treatment as follows (see subsection (3) of this section for clients of the division of developmental disabilities):
(i) Topical application of fluoride gel or fluoride varnish for adults age nineteen through sixty-four with xerostomia (requires prior authorization); and
(ii) Topical application of fluoride gel or fluoride varnish for adults age sixty-five and older for:
(A) Rampant root surface decay; or
(B) Xerostomia.
(g) Oral prophylaxis treatment, which is:
(i) Allowed once every twelve months for adults age nineteen and older, including nursing facility clients, and for clients of the division of developmental disabilities as provided in subsection (3) of this section;
(ii) Not reimbursed when oral prophylaxis treatment is performed on the same date of service as periodontal scaling and root planing, gingivectomy, or gingivoplasty; and
(iii) Reimbursed only if periodontal maintenance is not billed for the same client within the same twelve-month period.
(h) Restoration of teeth and maintenance of dental health, subject to the limitations in WAC 388-535-1265 and the following:
(i) Amalgam and composite restorations are allowed once for the same surface of the same tooth per client, per provider;
(ii) Multiple restorations involving the proximal and occlusal surfaces of the same tooth are considered to be a single multisurface restoration. Payment is limited to that of a single multisurface restoration.
(iii) Proximal restorations that do not involve the incisal angle in the anterior teeth are considered to be a two-surface restoration. Payment is limited to a two-surface restoration.
(iv) Proximal restorations that involve the incisal angle are considered to be either a three- or four-surface restoration. All surfaces must be listed on the claim for payment.
(v) MAA pays for a maximum of six surfaces for a posterior tooth, which is allowed once per client, per provider, in a two-year period.
(vi) MAA pays for a maximum of six surfaces for an anterior tooth, which is allowed once per client, per provider, in a two-year period.
(vii) MAA pays for a core buildup on an anterior or a posterior tooth, including any pins, which is allowed once per client, per provider, in a two-year period, subject to the following:
(A) MAA does not pay for a core buildup when a permanent or temporary crown is being placed on the same tooth.
(B) MAA does not pay for a core buildup when placed in combination with any other restoration on the same tooth.
(viii) MAA pays for flowable composites as a restoration only, when used with a cavity preparation for a carious lesion that penetrates through the enamel:
(A) As a small Class I (occlusal) restoration; or
(B) As a Class V (buccal or lingual) restoration.
(i) Endodontic (root canal) therapy for permanent anterior teeth only.
(j) Periodontal scaling and root planing, which is:
(i) Allowed for clients of the division of developmental disabilities as provided in subsection (3) of this section;
(ii) Allowed for clients age nineteen and older;
(iii) Allowed only when the client has radiographic evidence of periodontal disease. There must be supporting documentation in the client's record, including complete periodontal charting and a definitive periodontal diagnosis;
(iv) Allowed once per quadrant in a twenty-four month period;
(v) Allowed only when the client's clinical condition meets existing periodontal guidelines; and
(vi) Not allowed when performed on the same date of service as oral prophylaxis, periodontal maintenance, gingivectomy or gingivoplasty. Refer to subsection (2)(g) of this section for limitations on oral prophylaxis. Refer to subsection (2)(k) of this section for limitations on periodontal maintenance.
(k) Periodontal maintenance, which is:
(i) Allowed for clients of the division of developmental disabilities as provided in subsection (3) of this section;
(ii) Allowed for clients age nineteen and older;
(iii) Allowed only when the client has been previously treated for periodontal disease, including surgical or nonsurgical periodontal therapy;
(iv) Allowed when supporting documentation in the client's record includes a definitive periodontal diagnosis and complete periodontal charting;
(v) Allowed when the client's clinical condition meets existing periodontal guidelines;
(vi) Allowed when periodontal maintenance starts at least twelve months after completion of periodontal scaling and root planing or surgical treatment and paid only at twelve month intervals;
(vii) Not reimbursed when the periodontal maintenance is performed on the same date of service as periodontal scaling and root planing, gingivectomy, or gingivoplasty; and
(viii) Reimbursed only if oral prophylaxis is not billed for the same client within the same twelve-month period.
(l) Dentures and partial dentures according to WAC 388-535-1290.
(m) Simple extractions (includes local anesthesia, suturing, and routine postoperative care).
(n) Surgical extractions, subject to the following:
(i) Includes local anesthesia, suturing, and routine postoperative care; and
(ii) Requires documentation in the client's file to support soft tissue, partially bony, or completely bony extractions.
(o) Medically necessary oral surgery when coordinated with the client's managed care plan (if any).
(p) Palliative (emergency) treatment of dental pain and infections, minor procedures, which is:
(i) Allowed once per client, per day.
(ii) Reimbursed only when performed on a different date from:
(A) Any other definitive treatment necessary to diagnose the emergency condition; and
(B) Root canal therapy.
(iii) Reimbursed only when a description of the service is included in the client's record.
(q) Behavior management that requires the assistance of one additional dental professional staff for clients of the division of developmental disabilities. See subsection (3) of this section.
(3) For clients of the division of developmental disabilities, MAA allows services as follows:
(a) Fluoride application, either varnish or gel, three times per calendar year;
(b) One of the following combinations of preventive or periodontal procedures, subject to the limitations listed:
(i) Prophylaxis or periodontal maintenance, three times per calendar year;
(ii) Periodontal scaling and root planing, two times per calendar year; or
(iii) Prophylaxis or periodontal maintenance, two times per calendar year, and periodontal scaling and root planing, once per calendar year.
(c) Gingivectomy or gingivectoplasty, allowed for four or more contiguous teeth or bounded teeth spaces per quadrant, once every three years.
(d) Nitrous oxide;
(e) Behavior management that requires the assistance of one additional dental professional staff. A description of behavior management must be documented in the client's record;
(f) Panoramic radiographs;
(g) General anesthesia or conscious sedation with parenteral or multiple oral agents when medically necessary for providing treatment; and
(h) Limited visual oral assessment (does not replace an oral evaluation) when the assessment includes appropriate referrals, charting of patient data and oral health status and informing the client's parent or guardian of the results, and when at least one of the following occurs:
(i) The provision of triage services;
(ii) An intraoral screening of soft tissues by a public health dental hygienist to assess the need for prophylaxis, fluoride varnish, or referral for other dental treatments by a dentist; or
(iii) In circumstances where the client will be referred to a dentist for treatment, the referring provider will not provide treatment or provide a full evaluation at the time of the assessment.
(4) MAA covers dental services that are medically necessary and provided in a hospital under the direction of a physician or dentist for:
(a) The care or treatment of teeth, jaws, or structures directly supporting the teeth if the procedure requires hospitalization;
(b) Short stays when the procedure cannot be done in an office setting. See WAC 388-550-1100(6); and
(c) A hospital call, including emergency care, allowed one per day, per client, per provider.
(5) MAA covers general anesthesia and conscious sedation with parenteral or multiple oral agents for medically necessary dental services as follows:
(a) For treatment of clients who are eligible under the division of developmental disabilities.
(b) For oral surgery procedures.
(c) When justification for administering the general anesthesia instead of a lesser type of sedation is clearly documented in the client's record.
(d) When the anesthesia is administered by:
(i) An oral surgeon who has a current conscious sedation permit or a current general anesthesia permit from DOH;
(ii) An anesthesiologist;
(iii) A dental anesthesiologist who has a current conscious sedation permit or a current general anesthesia permit from DOH;
(iv) A certified registered nurse anesthetist (CRNA), if the performing dentist has a current conscious sedation permit or a current general anesthesia permit from the department of health (DOH); or
(v) A dentist who has a current conscious sedation permit or a current general anesthesia permit from DOH.
(e) When the provider meets the prevailing standard of care and at least the requirements in WAC 246-817-760, Conscious sedations with parenteral or multiple oral agents and WAC 246-817-770, General anesthesia.
(6) MAA pays for anesthesia services according to WAC 388-535-1350.
(7) MAA covers dental-related services for clients residing in nursing facilities or group homes as follows:
(a) Dental services must be requested by the client or the client's surrogate decision maker as defined in WAC 388-97-055, or a referral for services must be made by the attending physician, the director of nursing, or the nursing facility supervisor, as appropriate, allowed once per day (not per client and not per facility), per provider; and
(b) Nursing facilities must provide dental-related necessary services according to WAC 388-97-012, Nursing facility care)) The department covers dental-related diagnostic services only as listed in this section for clients age twenty-one and older (for dental-related services provided to clients eligible under the GA-U or ADATSA program, see WAC 388-535-1065).
(1) Clinical oral evaluations. The department covers:
(a) Oral health evaluations and assessments. The services must be documented in the client's record in accordance with WAC 388-502-0020;
(b) Periodic oral evaluations as defined in WAC 388-535-1050, once every twelve months. Twelve months must elapse between the comprehensive oral evaluation and the first periodic oral evaluation;
(c) Limited oral evaluations as defined in WAC 388-535-1050, only when the provider performing the limited oral evaluation is not providing routine scheduled dental services for the client. The limited oral evaluation:
(i) Must be to evaluate the client for a:
(A) Specific dental problem or oral health complaint;
(B) Dental emergency; or
(C) Referral for other treatment.
(ii) When performed by a denturist, is limited to the initial examination appointment. The department does not cover an additional limited oral examination by a denturist for the same client until three months after the removable prosthesis has been seated.
(d) Comprehensive oral evaluations as defined in WAC 388-535-1050, once per client, per provider or clinic, as an initial examination. The department covers an additional comprehensive oral evaluation if the client has not been treated by the same provider or clinic within the past five years;
(e) Limited visual oral assessments as defined in WAC 388-535-1050, up to two per client, per year, per provider only when the assessment is:
(i) Not performed in conjunction with other clinical evaluation services;
(ii) Performed to determine the need for fluoride treatment and/or when triage services are provided in settings other than dental offices or clinics; and
(iii) Provided by a licensed dentist or licensed dental hygienist.
(2) Radiographs (X-rays). The department:
(a) Covers radiographs that are of diagnostic quality, dated, and labeled with the client's name. The department requires original radiographs to be retained by the provider as part of the client's dental record, and duplicate radiographs to be submitted with prior authorization requests or when copies of dental records are required.
(b) Uses the prevailing standard of care to determine the need for dental radiographs.
(c) Covers intraoral complete series (includes four bitewings), once in a three-year period only if the department has not paid for a panoramic radiograph for the same client in the same three-year period.
(d) Covers periapical radiographs that are not included in a complete series. Documentation supporting the medical necessity for these must be in the client's record.
(e) Covers up to four bitewing radiographs once in a twelve month period.
(f) Covers panoramic radiographs in conjunction with four bitewings, once in a three-year period, only if the department has not paid for an intraoral complete series for the same client in the same three-year period.
(g) May cover panoramic radiographs for preoperative or postoperative surgery cases more than once in a three-year period, only on a case-by-case basis and when prior authorized.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-079, § 388-535-1255, filed 9/12/03, effective 10/13/03.]
(1) Dental prophylaxis. The department covers dental prophylaxis:
(a) Which includes scaling and polishing procedures to remove coronal plaque, calculus, and stains once every twelve months;
(b) Only when the service is performed twelve months after periodontal scaling and root planing, or periodontal maintenance services;
(c) Only when not performed on the same date of service as periodontal scaling and root planing, or periodontal maintenance, gingivectomy or gingivoplasty; and
(d) For clients of the division of development disabilities according to WAC 388-535-1099.
(2) Topical fluoride treatment. The department covers:
(a) Fluoride rinse, foam or gel, once within a twelve month period;
(b) Fluoride varnish, rinse, foam or gel for clients who are age sixty-five and older, or clients who reside in alternative living facilities, up to three times within a twelve-month period;
(c) Additional topical fluoride applications when prior authorized; and
(d) Topical fluoride treatment for clients of the division of developmental disabilities according to WAC 388-535-1099.
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(1) Amalgam restorations for permanent teeth. The department:
(a) Considers tooth preparation, all adhesives (including amalgam bonding agents), liners, bases, and polishing as part of the amalgam restoration;
(b) Considers the occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of the restoration;
(c) Considers buccal or lingual surface amalgam restorations, regardless of size or extension, as a one surface restoration. The department covers only one buccal and one lingual surface per tooth;
(d) Considers multiple amalgam restorations of fissures and grooves of the occlusal surface of the same tooth as a one surface restoration;
(e) Covers two occlusal amalgam restorations for teeth one, two, three, fourteen, fifteen, and sixteen, if the restorations are anatomically separated by sound tooth structure;
(f) Covers amalgam restorations for a maximum of five surfaces per tooth for a permanent posterior tooth, once per client, per provider or clinic, in a two-year period;
(g) Covers amalgam restorations for a maximum of six surfaces per tooth for teeth one, two, three, fourteen, fifteen and sixteen, once per client, per provider or clinic, in a two-year period. See also (e) of this subsection; and
(h) Does not pay for replacement of an amalgam restoration by the same provider on a permanent posterior tooth within a two-year period unless the restoration has an additional adjoining carious surface. The department pays for the replacement restoration as one multi-surface restoration. The client's record must include radiographs and documentation supporting the medical necessity for the replacement restoration.
(2) Resin-based composite restorations for permanent teeth. The department:
(a) Considers tooth preparation, acid etching, all adhesives (including resin bonding agents), liners and bases, polishing, and curing as part of the resin-based composite restoration;
(b) Considers the occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of the resin-based composite restoration;
(c) Considers buccal or lingual surface resin-based composite restorations, regardless of size or extension, as a one surface restoration. The department covers only one buccal and one lingual surface per tooth;
(d) Considers resin-based composite restorations of teeth where the decay does not penetrate the DEJ to be sealants. The department does not cover sealants for clients age twenty-one and older;
(e) Considers multiple preventive restorative resins or flowable composite resins for the occlusal, buccal, lingual, mesial, and distal fissures and grooves on the same tooth as a one surface restoration;
(f) Does not cover preventive restorative resin or flowable composite resin on the interproximal surfaces (mesial and/or distal) of posterior teeth or the incisal surface of anterior teeth;
(g) Covers two occlusal resin-based composite restorations for teeth one, two, three, fourteen, fifteen, and sixteen if the restorations are anatomically separated by sound tooth structure;
(h) Covers resin-based composite restorations for a maximum of five surfaces per tooth for a permanent posterior tooth, once per client, per provider or clinic, in a two-year period;
(i) Covers resin-based composite restorations for a maximum of six surfaces per tooth for permanent posterior teeth one, two, three, fourteen, fifteen and sixteen, once per client, per provider or clinic, in a two-year period. See also (g) of this subsection;
(j) Covers resin-based composite restorations for a maximum of six surfaces per tooth for a permanent anterior tooth, once per client, per provider or clinic, in a two-year period; and
(k) Does not pay for replacement of resin-based composite restorations by the same provider on permanent teeth within a two-year period unless the restoration has an additional adjoining carious surface. The department pays for the replacement restoration as one multi-surface restoration. The client's record must include radiographs and documentation supporting the medical necessity for the replacement restoration.
(3) Crowns. The department:
(a) Does not cover permanent crowns for clients age twenty-one and older, except for prefabricated stainless steel crowns for posterior permanent teeth on a case-by-case basis when prior authorized; and
(b) Covers crowns for clients of the division of developmental disabilities according to WAC 388-535-1099.
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(1) Pulpal debridement. The department covers pulpal debridement on permanent teeth. Pulpal debridement is not covered when performed with palliative treatment or when performed on the same day as endodontic treatment.
(2) Endodontic treatment. The department:
(a) Covers endodontic treatment for permanent anterior teeth only;
(b) Considers the following included in endodontic treatment:
(i) Pulpectomy when part of root canal therapy;
(ii) All procedures necessary to complete treatment; and
(iii) All intra-operative and final evaluation radiographs for the endodontic procedure.
(c) 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.
(d) Requires prior authorization for endodontic retreatment and considers endodontic retreatment to include:
(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 maxillary and mandibular anterior teeth only.
(e) 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.
(f) Does not pay for endodontic retreatment when provided by the original treating provider or clinic.
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3825.4(1) Surgical periodontal services. The department covers surgical periodontal services, including all postoperative care for clients of the division of development disabilities according to WAC 388-535-1099.
(2) Nonsurgical periodontal services. The department:
(a) Covers periodontal scaling and root planing once per quadrant, per client, in a two-year period when:
(i) The client has radiographic evidence of periodontal disease;
(ii) The client's record includes supporting documentation for the medical necessity, including complete periodontal charting and a definitive diagnosis of periodontal disease;
(iii) The client's clinical condition meets current published periodontal guidelines; and
(iv) Performed at least two years from the date of completion of periodontal scaling and root planing or surgical periodontal treatment.
(b) Considers ultrasonic scaling, gross scaling, or gross debridement to be included in the procedure and not a substitution for periodontal scaling and root planing.
(c) Covers periodontal scaling and root planing only when the services are not performed on the same date of service as prophylaxis, periodontal maintenance, gingivectomy, or gingivoplasty.
(d) Covers periodontal scaling and root planing for clients of the division of developmental disabilities according to WAC 388-535-1099.
(3) Other periodontal services. The department:
(a) Covers periodontal maintenance once per client in a twelve-month period when:
(i) The client has radiographic evidence of periodontal disease;
(ii) The client's record includes supporting documentation for medical necessity, including complete periodontal charting and a definitive diagnosis of periodontal disease;
(iii) The client's clinical condition meets existing published periodontal guidelines; and
(iv) Performed at least twelve months from the date of completion of periodontal scaling and root planing or surgical periodontal treatment.
(b) Covers periodontal maintenance only if performed on a different date of service as prophylaxis, periodontal scaling and root planing, gingivectomy, or gingivoplasty.
(c) Covers periodontal maintenance for clients of the division of developmental disabilities according to WAC 388-535-1099.
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(1) Removable prosthodontics. The department:
(a) Requires prior authorization requests for all removable prosthodontics and prosthodontic-related procedures listed in this subsection. Prior authorization requests must meet the criteria in WAC 535-1280. In addition, the department requires the dental provider to:
(i) Submit:
(A) Appropriate and diagnostic radiographs of all remaining teeth.
(B) A dental record that identifies:
(I) All missing teeth for both arches;
(II) Teeth that are to be extracted; and
(III) Dental and periodontal services completed on all remaining teeth.
(C) A prescription written by a dentist when a denturist's prior authorization request is for an immediate denture or cast metal partial denture.
(ii) Obtain a signed agreement of acceptance from the client at the conclusion of the final denture try-in for a department authorized complete denture or a cast-metal denture described in this section. If the client abandons the complete denture or the cast-metal partial denture after signing the agreement of acceptance, the department will deny subsequent requests for the same type dental prosthesis if the request occurs prior to the dates specified in this section. A copy of the signed agreement that documents the client's acceptance of the dental prosthesis must be submitted to the department's dental prior authorization section before the department pays the claim.
(b) Covers a complete denture, as follows:
(i) A complete denture, including an immediate denture or overdenture, is covered when prior authorized and the complete denture meets department coverage criteria;
(ii) Post-delivery care (e.g., adjustments, soft relines, and repairs) provided within three months of the seat date of a complete denture, is considered part of the complete denture procedure and is not paid separately;
(iii) Replacement of an immediate denture with a complete denture is covered only when the replacement occurs at least six months from the seat date of the immediate denture. The replacement complete denture must be prior authorized; and
(iv) Replacement of a complete denture or overdenture is covered only when the replacement occurs at least five years from the seat date of the complete denture or overdenture being replaced. The replacement denture must be prior authorized.
(c) Covers partial dentures as follows:
(i) Department authorization and payment for a resin or flexible base partial denture for anterior and posterior teeth is based on the following criteria:
(A) The remaining teeth in the arch must have a reasonable periodontal diagnosis and prognosis;
(B) The client has established caries control;
(C) One or more anterior teeth are missing, or four or more posterior teeth per arch are missing;
(D) There is a minimum of four stable teeth remaining per arch; and
(E) There is a three-year prognosis for retention of all remaining teeth.
(ii) Post-delivery care (e.g. adjustments, soft relines, and repairs) provided after three months from the seat date of the partial denture, is considered part of the partial denture and is not paid separately; and
(iii) Replacement of a resin or flexible base denture is covered only when the replacement occurs at least three years from the seat date of the partial denture being replaced. The replacement denture must be prior authorized and meet department coverage criteria.
(d) Covers cast metal framework partial dentures as follows:
(i) A cast metal framework with resin-based denture, including any conventional clasps, rests, and teeth, is covered on a case-by-case basis when prior authorized and department coverage criteria listed in (d)(iv) of this subsection are met.
(ii) Post-delivery care (e.g., adjustments, soft relines, and repairs) provided within three months of the seat date of the cast metal partial denture, is considered part of the partial denture procedure and is not paid separately.
(iii) Replacement of a cast metal framework partial denture is covered on a case-by-case basis and only when the replacement occurs at least five years from the seat date of the partial denture being replaced. The replacement denture must be prior authorized and meet department coverage criteria listed in (d)(iv) of this subsection.
(iv) Department authorization and payment for cast metal framework partial dentures is based on the following criteria:
(A) The remaining teeth in the arch must have a stable periodontal diagnosis and prognosis;
(B) The client has established caries control;
(C) All restorative and periodontal procedures must be completed before the request for prior authorization is submitted;
(D) There are fewer than eight posterior teeth in occlusion;
(E) There is a minimum of four stable teeth remaining per arch;
(F) There is a five-year prognosis, based on the sole discretion of the department, for retention of all remaining teeth.
(v) The department may consider resin partial dentures as an alternative if the criteria for cast metal framework partial dentures listed in (d)(iv) of this subsection do not meet department specifications.
(e) Requires the provider to bill for covered removable prosthetic procedures only after the seating of the prosthesis, not at the impression date. Refer to (2)(c) and (d) of this subsection if the removable prostheses is not delivered and inserted.
(f) Requires a provider to submit the following with prior authorization requests for removable prosthetics for a client residing in a nursing home, group home, or other facility:
(i) The client's medical diagnosis and prognosis;
(ii) The attending physician's request for prosthetic services;
(iii) The attending dentist's or denturist's statement documenting medical necessity;
(iv) A written and signed consent from the client's legal guardian when a guardian has been appointed; and
(v) A completed copy of the Denture/Partial Appliance Request for Skilled Nursing Facility Client form (DSHS 13-788) available from the department.
(g) Limits removable partial dentures to resin based partial dentures for all clients who reside in one of the facilities listed in (f) of this subsection. The department may consider cast metal partial dentures if the criteria in (d) of this subsection are met.
(h) Requires a provider to deliver services and procedures that are of acceptable quality to the department. The department may recoup payment for services that are determined to be below the standard of care or of an unacceptable product quality.
(2) Other services for removable prosthetics. The department covers:
(a) Repairs to complete and partial dentures;
(b) A laboratory reline or rebase to a complete or cast metal partial denture, once in a three-year period when performed at least six months after the seat date; and
(c) Laboratory fees, subject to all of the following:
(i) The department does not pay laboratory and professional fees for complete and partial dentures, except as stated in (ii) of this subsection;
(ii) The department may pay part of billed laboratory fees when the provider has obtained prior authorization from the department, and:
(A) At the time of delivery of the prosthesis, the patient is no longer an eligible medical assistance client (see also WAC 388-535-1280(3));
(B) The client moves from the state; or
(C) The client dies.
(iii) A provider must submit copies of laboratory prescriptions and receipts or invoices for each claim when billing for laboratory fees.
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(1) Oral and maxillofacial surgery services. The department:
(a) Requires enrolled dental providers who do not meet the conditions in WAC 388-535-1070(3) to bill claims for services that are listed in this subsection using only the Current Dental Terminology (CDT) codes.
(b) Requires enrolled providers (oral and maxillofacial surgeons) who meet the conditions in WAC 388-535-1070(3) to bill claims using Current Procedural Terminology (CPT) codes unless the procedure is specifically listed in the department's current published billing instructions as a CDT covered code (e.g., extractions).
(c) Does not cover oral surgery services described in WAC 388-535-1267 that are performed in a hospital operating room or ambulatory surgery center.
(d) Requires the client's record to include supporting documentation for each type of extraction or any other surgical procedure billed to the department. The documentation must include:
(i) An appropriate consent form signed by the client or the client's legal representative;
(ii) Appropriate radiographs;
(iii) Medical justification with diagnosis;
(iv) Client's blood pressure, when appropriate;
(v) A surgical narrative;
(vi) A copy of the post-operative instructions; and
(vii) A copy of all pre- and post-operative prescriptions.
(e) Covers routine and surgical extractions.
(f) Covers debridement of a granuloma or cyst that is five millimeters or greater in diameter. The department includes debridement of a granuloma or cyst that is less than five millimeters as part of the global fee for the extraction.
(g) Covers biopsy, as follows:
(i) Biopsy of soft oral tissue or brush biopsy do not require prior authorization; and
(ii) All biopsy reports must be kept in the client's record.
(h) Covers alveoloplasty only when three or more teeth are extracted per arch.
(i) Covers surgical excision of soft tissue lesions only on a case-by-case basis and when prior authorized.
(j) Covers only the following excisions of bone tissue in conjunction with placement of immediate, complete, or partial dentures when prior authorized:
(i) Removal of lateral exostosis;
(ii) Removal of torus palatinus or torus mandibularis; and
(iii) Surgical reduction of soft tissue or osseous tuberosity.
(2) Surgical incision-related services. The department covers the following surgical incision-related services:
(a) Uncomplicated intraoral and extraoral soft tissue incision and drainage of abscess. The department does not cover this service when combined with an extraction or root canal treatment. Documentation supporting medical necessity must be in the client's record; and
(b) Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue when prior authorized. Documentation supporting medical necessity must be in the client's record.
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(1) Adjunctive general services. The department:
(a) Covers palliative (emergency) treatment, not to include pulpal debridement, for treatment of dental pain, limited to once per day, per client, as follows:
(i) The treatment must occur during limited evaluation appointments;
(ii) A comprehensive description of diagnosis and services provided must be documented in the client's record; and
(iii) Appropriate radiographs must be in the client's record to support medical necessity for the treatment.
(b) Covers local anesthesia and regional blocks as part of the global fee for any procedure being provided to clients.
(c) Covers office based oral or parenteral sedation:
(i) For services listed as covered in WAC 388-535-1267;
(ii) For all current published Current Procedural Terminology (CPT) dental codes;
(iii) When the provider's current valid anesthesia permit is on file with the department; and
(iv) For clients of the division of developmental disabilities according to WAC 388-535-1099.
(d) Covers office based general anesthesia for:
(i) Extraction of three or more teeth;
(ii) Services listed as covered in WAC 388-535-1267 (1)(h) and (j);
(iii) For all current published CPT dental codes;
(iv) When the provider's current valid anesthesia permit is on file with the department; and
(v) For clients of the division of developmental disabilities, according to WAC 388-535-1099.
(e) Covers inhalation of nitrous oxide, once per day.
(f) Requires providers of oral or parenteral conscious sedation, or general anesthesia to meet:
(i) The prevailing standard of care;
(ii) The provider's professional organizational guidelines;
(iii) The requirements in chapter 246-817 WAC; and
(iv) Relevant department of health (DOH) medical, dental, and nursing anesthesia regulations;
(g) Pays for anesthesia services according to WAC 388-535-1350;
(h) Covers professional consultation/diagnostic services as follows:
(i) A dentist or a physician other than the practitioner providing treatment must provide the services; and
(ii) A client must be referred by the department for the services to be covered.
(2) Nonemergency dental services. The department covers nonemergency dental services performed in a hospital or ambulatory surgical center for clients of the division of developmental disabilities according to WAC 388-535-1099.
(3) Professional visits. The department covers:
(a) Up to two house/extended care facility calls (visits) per facility, per provider. The department limits payment to two facilities per day, per provider.
(b) One hospital call (visit), including emergency care, per day, per provider, per client. The department does not pay for additional hospital calls if billed for the same client on the same day.
(c) Emergency office visits after regularly scheduled hours. The department limits payment to one emergency visit per day, per provider.
(4) Drugs and/or medicaments (pharmaceuticals). The department covers drugs and/or medicaments (pharmaceuticals) only when used with parenteral conscious sedation, deep sedation, or general anesthesia. The department's dental program does not pay for oral sedation medications.
(5) Miscellaneous services. The department covers:
(a) Behavior management that requires the assistance of one additional dental staff other than the dentist only for clients of the division of developmental disabilities. See WAC 388-535-1099.
(b) Treatment of post-surgical complications (e.g., dry socket). Documentation supporting the medical necessity for the service must be in the client's record.
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3826.3(a) The dental-related services and procedures described in subsection (2) of this section;
(b) Any service specifically excluded by statute;
(c) More costly services when less costly, equally effective services as determined by the department are available; and
(d) Services, procedures, treatment, devices, drugs, or application of associated services:
(i) Which the department or the Centers for Medicare and Medicaid Services (CMS) considers investigative or experimental on the date the services were provided.
(ii) That are not listed as covered in one or both of the following:
(A) Washington Administrative Code (WAC).
(B) The department's published documents (e.g., billing instructions).
(2) The department does not cover dental-related services listed under the following categories of service for clients age twenty-one and older:
(a) Diagnostic services. The department does not cover:
(i) Detailed and extensive oral evaluations or re-evaluations;
(ii) Comprehensive periodontal evaluations;
(iii) Extraoral or occlusal intraoral radiographs;
(iv) Posterior-anterior or lateral skull and facial bone survey films;
(v) Sialography;
(vi) Any temporomandibular joint films;
(vii) Tomographic survey;
(viii) Cephalometric films;
(ix) Oral/facial photographic images;
(x) Viral cultures, genetic testing, caries susceptibility tests, adjunctive pre-diagnostic tests, or pulp vitality tests; or
(xi) Diagnostic casts.
(b) Preventive services. The department does not cover:
(i) Nutritional counseling for control of dental disease;
(ii) Tobacco counseling for the control and prevention of oral disease;
(iii) Oral hygiene instructions (included as part of the global fee for oral prophylaxis);
(iv) Removable space maintainers of any type;
(v) Sealants;
(vi) Space maintainers of any type or recementation of space maintainers; or
(vii) Fluoride trays of any type.
(c) Restorative services. The department does not cover:
(i) Restorative/operative procedures performed in a hospital operating room or ambulatory surgical center for clients age twenty-one and older. For clients of the division of developmental disabilities, see WAC 388-535-1099;
(ii) Gold foil restorations;
(iii) Metallic, resin-based composite, or porcelain/ceramic inlay/onlay restorations;
(iv) Prefabricated resin crowns;
(v) Temporary or provisional crowns (including ion crowns);
(vi) Any type of permanent or temporary crown. For clients of the division of developmental disabilities see WAC 388-535-1099;
(vii) Recementation of any crown, inlay/onlay, or any other type of indirect restoration;
(viii) Sedative fillings;
(ix) Preventive restorative resins;
(x) Any type of core buildup, cast post and core, or prefabricated post and core;
(xi) Labial veneer resin or porcelain laminate restoration;
(xii) Any type of coping;
(xiii) Crown repairs; or
(xix) Polishing or recontouring restorations or overhang removal for any type of restoration.
(d) Endodontic services. The department does not cover:
(i) Indirect or direct pulp caps;
(ii) Endodontic therapy on any primary teeth for clients age twenty-one and older;
(iii) Endodontic therapy on permanent bicuspids or molar teeth;
(iv) Any apexification/recalcification procedures;
(v) Any apicoectomy/periradicular service; or
(vi) Any surgical endodontic procedures including, but not limited to, retrograde fillings, root amputation, reimplantation, and hemisections.
(e) Periodontic services. The department does not cover:
(i) Surgical periodontal services that include, but are not limited to:
(A) Gingival or apical flap procedures;
(B) Clinical crown lengthening;
(C) Any type of osseous surgery;
(D) Bone or soft tissue grafts;
(E) Biological material to aid in soft and osseous tissue regeneration;
(F) Guided tissue regeneration;
(G) Pedicle, free soft tissue, apical positioning, subepithelial connective tissue, soft tissue allograft, combined connective tissue and double pedicle, or any other soft tissue or osseous grafts; or
(H) Distal or proximal wedge procedures; or
(ii) Nonsurgical periodontal services, including but not limited to:
(A) Intracoronal or extracoronal provisional splinting;
(B) Full mouth debridement;
(C) Localized delivery of chemotherapeutic agents; or
(D) Any other type of nonsurgical periodontal service.
(f) Prosthodontics (removable). The department does not cover any type of:
(i) Removable unilateral partial dentures;
(ii) Adjustments to any removable prosthesis;
(iii) Chairside complete or partial denture relines;
(iv) Any interim complete or partial denture;
(v) Precision attachments; or
(vi) Replacement of replaceable parts for semi-precision or precision attachments.
(g) Oral and maxillofacial prosthetic services. The department does not cover any type of oral or facial prosthesis other than those listed in WAC 388-535-1266.
(h) Implant services. The department does not cover:
(i) Any implant procedures, including, but not limited to, any tooth implant abutment (e.g., periosteal implant, eposteal implant, and transosteal implant), abutments or implant supported crown, abutment supported retainer, and implant supported retainer;
(ii) Any maintenance or repairs to procedures listed in (h)(i) of this subsection; or
(iii) The removal of any implant as described in (h)(i) of this subsection.
(i) Prosthodontics (fixed). The department does not cover any type of:
(i) Fixed partial denture pontic;
(ii) Fixed partial denture retainer;
(iii) Precision attachment, stress breaker, connector bar, coping, or cast post; or
(iv) Other fixed attachment or prosthesis.
(j) Oral and maxillofacial surgery. The department does not cover:
(i) Any nonemergency oral surgery performed in a hospital or ambulatory surgical center for Current Dental Terminology (CDT) procedures;
(ii) Vestibuloplasty;
(iii) Frenuloplasty/frenulectomy;
(iv) Any oral surgery service not listed in WAC 388-535-1267;
(v) Any oral surgery service that is not listed in the department's list of covered Current Procedural Terminology (CPT) codes published in the department's current rules or billing instructions;
(vi) Any type of occlusal orthotic splint or device, bruxing or grinding splint or device, temporomandibular joint splint or device, or sleep apnea splint or device; or
(vii) Any type of orthodontic service or appliance.
(k) Adjunctive general services. The department does not cover:
(i) Anesthesia to include:
(A) Local anesthesia as a separate procedure;
(B) Regional block anesthesia as a separate procedure;
(C) Trigeminal division block anesthesia as a separate procedure;
(D) Analgesia or anxiolysis as a separate procedure except for inhalation of nitrous oxide;
(E) Medication for oral sedation, or therapeutic drug injections, including antibiotic or injection of sedative; or
(F) Application of any type of desensitizing medicament or resin.
(ii) Other general services including, but not limited to:
(A) Fabrication of athletic mouthguard, occlusal guard, or nightguard;
(B) Occlusion analysis;
(C) Occlusal adjustment or odontoplasties;
(D) Enamel microabrasion;
(E) Dental supplies, including but not limited to, toothbrushes, toothpaste, floss, and other take home items;
(F) Dentist's or dental hygienist's time writing or calling in prescriptions;
(G) Dentist's or dental hygienist's time consulting with clients on the phone;
(H) Educational supplies;
(I) Nonmedical equipment or supplies;
(J) Personal comfort items or services;
(K) Provider mileage or travel costs;
(L) Missed or late appointment fees;
(M) Service charges of any type, including fees to create or copy charts;
(N) Office supplies used in conjunction with an office visit; or
(O) Teeth whitening services or bleaching, or materials used in whitening or bleaching.
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(1) The department uses the determination process described in WAC 388-501-0165 for covered dental-related services for clients age twenty-one and older that require prior authorization.
(2) ((MAA)) The department requires a dental provider who
is requesting prior authorization to submit sufficient
objective clinical information to establish medical necessity.
The request must be submitted in writing on an American
Dental ((Assoc6iation)) Association
(ADA) claim form, which may be obtained by writing to the
American Dental Association, 211 East Chicago Avenue, Chicago,
Illinois 60611. ((The request must include at least all of
the following:
(a) The client's patient identification code (PIC);
(b) The client's name and address;
(c) The provider's name and address;
(d) The provider's telephone and fax number (including area code);
(e) The provider's MAA-assigned seven-digit provider number;
(f) The physiological description of the disease, injury, impairment, or other ailment;
(g) The most recent and relevant radiographs that are identified with client name, provider name, and date the radiograph was taken;
(h) The treatment plan;
(i) Periodontal when radiographs do not sufficiently support the medical necessity for extractions;
(j) Study model, if requested; and
(k) Photographs, if requested.
(2) MAA considers requests for services according to WAC 388-535-1270.
(3) MAA denies a request for dental services when the requested service is:
(a) Not listed in chapter 388-535 WAC as a covered service;
(b) Not medically necessary;
(c) A service, procedure, treatment, device, drug, or application of associated service that the department or the Centers for Medicare and Medicaid Services (CMS) consider investigative or experimental on the date the service is provided; or
(d) Covered under another department program or by an agency outside the department.
(4) MAA may require second opinions and/or consultations before authorizing any procedure.
(5) Authorization is valid only if the client is eligible for covered services on the date of service))
(3) The department may request additional information as follows:
(a) Additional radiographs (x-rays) (refer to WAC 388-535-1255(2));
(b) Study models;
(c) Photographs; and
(d) Any other information as determined by the department.
(4) The department may require second opinions and/or consultations before authorizing any procedure.
(5) When the department authorizes a dental-related service for a client, that authorization indicates only that the specific service is medically necessary, it is not a guarantee of payment. The authorization is valid for six months and only if the client is eligible for covered services on the date of service.
(6) The department denies a request for a dental-related service when the requested service:
(a) Is covered by another department program;
(b) Is covered by an agency or other entity outside the department; or
(c) Fails to meet the program criteria, limitations, or restrictions in chapter 388-535 WAC.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-080, § 388-535-1280, filed 9/12/03, effective 10/13/03.]
The following sections of the Washington Administrative Code are repealed:
| WAC 388-535-1270 | Dental-related services requiring prior authorization -- Adults. |
| WAC 388-535-1290 | Dentures and partial dentures for adults. |