PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 06-21-067.
Title of Rule and Other Identifying Information: Part 1 of 4: New sections WAC 388-535-1079 Dental-related services for clients through age twenty -- General and 388-535-1082 Covered dental-related services for clients through age twenty -- Preventive services; and amending WAC 388-535-1080 Covered dental-related services for clients through age twenty -- Diagnostic.
Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane, behind Goodyear Tire. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on January 9, 2007, at 10:00 a.m.
Date of Intended Adoption: Not earlier than January 10, 2007.
Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m. on January 9, 2007.
Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by January 5, 2007, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The new and amended sections clarify and update policies for dental-related services for clients though age twenty; 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; and clarify additional benefits and limitations associated with those services for clients through age twenty.
Reasons Supporting Proposal: To clarify new dental-related services covered and the limitations associated with those services; to make HRSA's rules regarding covered and noncovered dental-related services for clients through age twenty clearer and easier to understand for clients and dental providers; and to identify the requirements and criteria that must be met in order to obtain covered dental-related services.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.500, 74.09.520.
Statute Being Implemented: RCW 74.08.090, 74.09.500, 74.09.520.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Department of social and health services, governmental.
Name of Agency Personnel Responsible for Drafting: Kathy Sayre, 626 8th Avenue, Olympia, WA 98504-5504, (360) 725-1342; Implementation and Enforcement: Dr. John Davis, 626 8th Avenue, Olympia, WA 98504-5504, (360) 725-1748.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rules do not create more than minor costs for small businesses.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Dr. John Davis, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1748, TYY/TDD 1-800-848-5429, fax (360) 586-1590, e-mail davisjd@dshs.wa.gov.
November 30, 2006
Andy Fernando, Manager
Rules and Policies Assistance Unit
3804.5(a) Are within the scope of an eligible client's medical care program;
(b) Are medically necessary;
(c) Meet the department's prior authorization requirements, if any;
(d) Are within accepted dental or medical practice standards;
(e) Are consistent with a diagnosis of dental disease or condition;
(f) Are reasonable in amount and duration of care, treatment, or service; and
(g) Are listed as covered in the department's published rules, billing instructions and fee schedules.
(2) Under the Early Periodic Screening and Diagnostic Treatment (EPSDT) program, clients ages twenty and younger may be eligible for the dental-related services listed as noncovered in WAC 388-535-1100, if the services include those medically necessary services and other measures provided to correct or ameliorate conditions discovered during a screening performed under the EPSDT program. See WAC 388-534-0100 for information about EPSDT.
(3) Clients who are eligible for services through the division of developmental disabilities may receive dental-related services according to WAC 388-535-1099.
(4) 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 according to WAC 388-501-0160.
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(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 children:
(a) Medically necessary services for the identification of dental problems or the prevention of dental disease, subject to the limitations of this chapter;
(b) Oral health evaluations and assessments, which must be documented in the client's file according to WAC 388-502-0020, as follows:
(i) MAA allows a comprehensive oral evaluation once per provider as an initial examination, and it must include:
(A) An oral health and developmental history;
(B) An assessment of physical and oral health status; and
(C) Health education, including anticipatory guidance.
(ii) MAA allows a periodic oral evaluation once every six months. Six months must elapse between the comprehensive oral evaluation and the first periodic oral evaluation.
(iii) MAA allows a limited oral evaluation only when the provider performing the limited oral evaluation is not providing prescheduled dental services for the client. The limited oral evaluation must be:
(A) To provide limited or emergent services for a specific dental problem; or
(B) To provide an evaluation for a referral.
(c) Radiographs as follows:
(i) Intraoral (complete series, including bitewings), allowed once in a three-year period;
(ii) Bitewings, total of four allowed every twelve months; and
(iii) Panoramic, for oral surgical purposes only, as follows:
(A) Not allowed with an intraoral complete series; and
(B) Allowed once in a three-year period, except for preoperative or postoperative surgery cases. Preoperative radiographs must be provided within fourteen days prior to surgery, and postoperative radiographs must be provided within thirty days after surgery.
(d) Fluoride treatment (either gel or varnish, but not both) as follows for clients through age eighteen (additional applications require prior authorization):
(i) Topical application of fluoride gel, once every six months; or
(ii) Topical application of fluoride varnish, up to three times in a twelve-month period;
(iii) See subsection (3) of this section for clients of the division of developmental disabilities.
(e) Sealants for children only, once per tooth in a three-year period for:
(i) The occlusal surfaces of:
(A) Permanent teeth two, three, fourteen, fifteen, eighteen, nineteen, thirty, and thirty-one only; and
(B) Primary teeth A, B, I, J, K, L, S, and T only.
(ii) The lingual pits of teeth seven and ten; and
(iii) Teeth with no decay.
(f) Prophylaxis treatment, which is allowed:
(i) Once every six months for children age eight through eighteen;
(ii) Only as a component of oral hygiene instruction for children through age seven; and
(iii) For clients of the division of developmental disabilities, see subsection (3) of this section.
(g) Space maintainers, for children through age eighteen only, as follows:
(i) Fixed (unilateral type), one per quadrant;
(ii) Fixed (bilateral type), one per arch; and
(iii) Recementation of space maintainer, once per quadrant or arch.
(h) Amalgam or composite restorations, as follows:
(i) Once in a two-year period; and
(ii) For the same surface of the same tooth.
(i) Crowns as described in WAC 388-535-1230, Crowns;
(j) Restoration of teeth and maintenance of dental health, subject to limitations of WAC 388-535-1100 and as follows:
(i) Multiple restorations involving the proximal and occlusal surfaces of the same tooth are considered to be a multisurface restoration, and are reimbursed as such; and
(ii) Proximal restorations that do not involve the incisal angle in the anterior tooth are considered to be a two-surface restoration, and are reimbursed as such;
(k) Endodontic (root canal) therapies for permanent teeth except for wisdom teeth;
(l) Therapeutic pulpotomies, once per tooth, on primary teeth only;
(m) Pulp vitality test, as follows:
(i) Once per day (not per tooth);
(ii) For diagnosis of emergency conditions only; and
(iii) Not allowed when performed on the same date as any other procedure, with the exception of an emergency examination or palliative treatment.
(n) Periodontal scaling and root planing as follows:
(i) See subsection (3) of this section for clients of the division of developmental disabilities;
(ii) Only when the client has radiographic (X-ray) evidence of periodontal disease. There must be supporting documentation, including complete periodontal charting and a definitive periodontal diagnosis;
(iii) Once per quadrant in a twenty-four month period; and
(iv) Not allowed when performed on the same date of service as prophylaxis, periodontal maintenance, gingivectomy, or gingivoplasty.
(o) Periodontal maintenance as follows:
(i) See subsection (3) of this section for clients of the division of developmental disabilities;
(ii) Only when the client has radiographic (X-ray) evidence of periodontal disease. There must be supporting documentation, including complete periodontal charting and a definitive periodontal diagnosis;
(iii) Once per full mouth in a twelve-month period; and
(iv) Not allowed when performed on the same date of service as prophylaxis, periodontal scaling, gingivectomy, or gingivoplasty..
(p) Complex orthodontic treatment for severe handicapping dental needs as specified in chapter 388-535A WAC, Orthodontic services;
(q) Occlusal orthotic appliance for temporomandibular joint disorder (TMJ/TMD) or bruxism, one in a two-year period;
(r) Medically necessary oral surgery when coordinated with the client's managed care plan (if any);
(s) Dental services or treatment necessary for the relief of pain and infections, including removal of symptomatic wisdom teeth. MAA does not cover routine removal of asymptomatic wisdom teeth without justifiable medical indications;
(t) Behavior management for clients through age eighteen only, whose documented behavior requires the assistance of more than one additional dental professional staff to protect the client from self-injury during treatment. See subsection (3) of this section for clients of the division of developmental disabilities.
(u) Nitrous oxide for children through age eighteen only, when medically necessary. See subsection (3) of this section for clients of the division of developmental disabilities.
(v) Professional visits, as follows:
(i) Bedside call at a nursing facility or residence when requested by the client or the client's surrogate decision maker as defined in WAC 388-97-055, or when a referral for services is 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.
(ii) Hospital call, including emergency care, allowed one per day.
(w) Emergency palliative treatment, as follows:
(i) Allowed only when no other definitive treatment is performed on the same day; and
(ii) Documentation must include tooth designation and a brief description of the service.
(3) For clients of the division of developmental disabilities, MAA allows services as follows:
(a) Fluoride application, either varnish or gel, allowed three times per calendar year;
(b) Prophylaxis, allowed three times per calendar year;
(c) Periodontal scaling and root planing, allowed once every six months;
(d) Periodontal maintenance, allowed three times every twelve months;
(e) Nitrous oxide;
(f) Behavior management that requires the assistance of one additional dental professional staff; and
(g) Panoramic radiographs, with documentation that behavior management is required.
(4) MAA covers medically necessary services 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; and
(b) Short stays when the procedure cannot be done in an office setting. See WAC 388-550-1100(6), Hospital coverage.
(5) MAA covers anesthesia for medically necessary services as follows:
(a) The anesthesia must be administered by:
(i) An oral surgeon;
(ii) An anesthesiologist;
(iii) A dental anesthesiologist;
(iv) A certified registered nurse anesthetist (CRNA); or
(v) A general dentist who has a current conscious sedation permit from the department of health (DOH).
(b) MAA pays for anesthesia services according to WAC 388-535-1350.
(6) For clients residing in nursing facilities or group homes:
(a) Dental services must be requested by the client or a referral for services made by the attending physician, the director of nursing or the nursing facility supervisor, or the client's legal guardian;
(b) Mass screening for dental services of clients residing in a facility is not permitted; and
(c) Nursing facilities must provide dental-related necessary services according to WAC 388-97-012, Nursing facility care.
(7) A request to exceed stated limitations or other restrictions on covered services is called a limitation extension (LE), which is a form of prior authorization. MAA evaluates and approves requests for LE for dental-related services when medically necessary, under the provisions of WAC 388-501-0165)) The department covers medically necessary dental-related diagnostic services, subject to the coverage limitations listed, for clients through age twenty as follows:
(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 six months. Six 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 any additional limited examination by a denturist for the same client until three months after a 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 oral evaluation services;
(ii) Performed to determine the need for sealants or 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 requested.
(b) Uses the prevailing standard of care to determine the need for dental radiographs.
(c) Covers an 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 included in the client's record.
(e) Covers an occlusal intraoral radiograph once in a two-year period. Documentation supporting the medical necessity for these must be included in the client's record.
(f) Covers a maximum of two bitewing radiographs once every twelve months for clients through age eleven.
(g) Covers a maximum of four bitewing radiographs once every twelve months for clients ages twelve through twenty.
(h) 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.
(i) 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.
(j) Covers cephalometric film:
(i) For orthodontics, as described in chapter 388-535A WAC; or
(ii) Only on a case-by-case basis and when prior authorized.
(k) Covers radiographs not listed as covered in this subsection, only on a case-by-case basis and when prior authorized.
(l) Covers oral and facial photographic images, only on a case-by-case basis and when requested by the department.
(3) Tests and examinations. The department covers:
(a) One pulp vitality test per visit (not per tooth):
(i) For diagnosis only during limited oral evaluations; and
(ii) When radiographs and/or documented symptoms justify the medical necessity for the pulp vitality test.
(b) Diagnostic casts other than those included in an orthodontic case study, on a case-by-case basis, and when requested by the department.
[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. 03-19-078, § 388-535-1080, 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, § 388-535-1080, filed 6/14/02, effective 7/15/02. 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, § 388-535-1080, filed 3/10/99, effective 4/10/99.]
(1) Dental prophylaxis. The department covers prophylaxis:
(a) Which includes scaling and polishing procedures to remove coronal plaque, calculus, and stains when performed on primary, transitional, or permanent dentition, once every six months for clients through age eighteen.
(b) Which includes scaling and polishing procedures to remove coronal plaque, calculus, and stains when performed on transitional or permanent dentition, once every twelve months for clients ages nineteen through twenty.
(c) Only when the service is performed six months after periodontal scaling and root planing, or periodontal maintenance services, for clients ages thirteen through eighteen.
(d) Only when the service is performed twelve months after periodontal scaling and root planing, or periodontal maintenance services for clients ages nineteen through twenty.
(e) Only when not performed on the same date of service as periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty.
(f) For clients of the division of developmental disabilities according to WAC 388-535-1099.
(2) Topical fluoride treatment. The department covers:
(a) Fluoride varnish, rinse, foam or gel for clients ages six and younger, up to three times within a twelve-month period.
(b) Fluoride varnish, rinse, foam or gel for clients ages seven through eighteen, up to two times within a twelve-month period.
(c) Fluoride varnish, rinse, foam or gel, up to three times within a twelve-month period during orthodontic treatment.
(d) Fluoride rinse, foam or gel for clients ages nineteen through twenty, once within a twelve-month period.
(e) Additional topical fluoride applications only on a case-by-case basis and when prior authorized.
(f) Topical fluoride treatment for clients of the division of developmental disabilities according to WAC 388-535-1099.
(3) Oral hygiene instruction. The department covers:
(a) Oral hygiene instruction only for clients through age eight.
(b) Oral hygiene instruction up to two times within a twelve-month period.
(c) Individualized oral hygiene instruction for home care to include tooth brushing technique, flossing, and use of oral hygiene aides.
(d) Oral hygiene instruction only when not performed on the same date of service as prophylaxis.
(e) Oral hygiene instruction only when provided by a licensed dentist or a licensed dental hygienist and the instruction is provided in a setting other than a dental office or clinic.
(4) Sealants. The department covers:
(a) Sealants only when used on a mechanically and/or chemically prepared enamel surface.
(b) Sealants once per tooth in a three-year period for clients through age eighteen.
(c) Sealants only when used on the occlusal surfaces of:
(i) Permanent teeth two, three, fourteen, fifteen, eighteen, nineteen, thirty, and thirty-one; and
(ii) Primary teeth A, B, I, J, K, L, S, and T.
(d) Sealants only if evidence of occlusal or interproximal decay has not penetrated to the dentoenamel junction (DEJ).
(e) Sealants only when placed on a tooth with no pre-existing occlusal restoration, or any occlusal restoration placed on the same day.
(f) Additional sealants on a case-by-case basis and when prior authorized.
(5) Space maintenance. The department covers:
(a) Fixed unilateral or fixed bilateral space maintainers for clients through age eighteen.
(b) Only one space maintainer per quadrant.
(c) Space maintainers only for missing primary molars A, B, I, J, K, L, S, and T.
(d) Replacement space maintainers only on a case-by-case basis and when prior authorized.
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