Effective Date of Rule: April 28, 2011.

     Purpose: Upon order of the governor, the medicaid purchasing administration (MPA) must reduce its budget expenditures for the current fiscal year ending June 30, 2011, by 6.3 percent. To achieve this expenditure reduction, MPA is eliminating nonemergency dental and dental-related services for clients twenty-one years of age and older. Clients who are classified as developmentally disabled under RCW 71A.10.020 who are twenty-one years of age and older will continue to receive dental-related services under chapter 388-535 WAC. In addition, the rules meet targeted budget expenditure levels under sections 201 and 209 of the operating budget for fiscal years 2010 and 2011.

     Citation of Existing Rules Affected by this Order: Repealing WAC 388-535-1247, 388-535-1255, 388-535-1257, 388-535-1259, 388-535-1261, 388-535-1263, 388-535-1266, 388-535-1267, 388-535-1269, 388-535-1271 and 388-535-1280; and amending WAC 388-535-1060, 388-535-1065, 388-535-1079, 388-535-1080, 388-535-1082, 388-535-1084, 388-535-1086, 388-535-1088, 388-535-1090, 388-535-1092, 388-535-1094, 388-535-1096, 388-535-1098, 388-535-1099, 388-535-1100, 388-535-1220, 388-535-1350, 388-535-1400, 388-535-1450, and 388-535-1500.

     Statutory Authority for Adoption: RCW 74.08.090.

     Other Authority: Section 209(1), chapter 37, Laws of 2010 (ESSB 6444); sections 201 and 209, chapter 564, Laws of 2009 (ESHB 1244).

     Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule; and that in order to implement the requirements or reductions in appropriations enacted in any budget for fiscal years 2009, 2010, or 2011, which necessitates the need for the immediate adoption, amendment, or repeal of a rule, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the fiscal needs or requirements of the agency.

     Reasons for this Finding: Governor Gregoire issued Executive Order 10-04 on September 13, 2010, under the authority of RCW 43.88.110(7). In the executive order, the governor required DSHS and all other state agencies to reduce their expenditures in state fiscal year 2011 by approximately 6.3 percent. As a consequence of the executive order, funding will no longer be available as of January 1, 2011, for the benefits that are being eliminated as part of these regulatory amendments. Delaying the adoption of these cuts to optional services could jeopardize the state's ability to maintain the mandatory medicaid programs for the majority of DSHS clients. The rule continues the emergency rule filed under WSR 11-02-10 [11-02-030] on December 19 [29], 2010, to comply with Executive Order 10-04, and also continues the emergency rule filed under WSR 10-22-053 on October 28, 2010, that complies with sections 201 and 209 of the operating budget for fiscal years 2010 and 2011 with respect to dental services. CR-101s were filed under WSR 09-14-093 on June 30, 2009, and WSR 10-20-160 on October 6, 2010. MPA is currently preparing drafts for the permanent rule to share with providers for their input. Following this, MPA plans to formally adopt the permanent rule.

     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 0, Amended 20, Repealed 11.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 20, Repealed 11.

     Date Adopted: April 19, 2011.

Katherine I. Vasquez

Rules Coordinator

     (1) ((Children eligible for the)) A client twenty years of age or younger who is eligible under one of the following medical assistance programs:

     (a) Categorically needy program (CN or CNP);

     (b) Categorically needy program - children's health insurance program (CNP-CHIP); ((and))

     (c) ((Limited casualty program - )) Medically needy program (((LCP-MNP))) (MNP); or

     (d) Disability lifeline (formerly general assistance-unemployable (GAU) or alcohol and drug abuse treatment and support act (ADATSA).

     (((2) Adults eligible for the:

     (a) Categorically needy program (CN or CNP); and

     (b) Limited casualty program - medically needy program (LCP-MNP).

     (3) Clients eligible for medical care services under the following state-funded only programs are eligible only for the limited dental-related services described in WAC 388-535-1065:

     (a) General assistance - Unemployable (GA-U); and

     (b) General assistance - Alcohol and Drug Abuse Treatment and Support Act (ADATSA) (GA-W).

     (4))) (2) A client of the division of developmental disabilities.

     (3) A client((s)) ((who are)) twenty years of age or younger enrolled in a department-contracted managed care ((plan are eligible for medical assistance administration (MAA)-covered dental services that are not covered by their plan,)) organization (MCO). MCO clients are eligible under fee-for-service((,)) for covered dental-related services not covered by their MCO plan, subject to the provisions of chapter 388-535 WAC and other applicable ((WAC)) department rules.

     (4) See WAC 388-438-0120 for rules for clients eligible under an alien emergency medical program.

[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, § 388-535-1060, 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, § 388-535-1060, 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, § 388-535-1060, filed 3/10/99, effective 4/10/99.]

     (2))) The department covers the following dental-related services only for a client ((eligible under the GA-U)) who is twenty years of age or younger and eligible under the disability lifeline or ADATSA program:

     (a) 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) Panographs that are medically necessary to diagnose only the client's chief complaint;

     (iv) Palliative treatment to relieve dental pain;

     (((iv))) (v) Pulpal debridement to relieve dental pain; or

     (((v))) (vi) 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 abscessed;

     (iii) The tooth is not restorable; or

     (iv) The tooth is not periodontally stable.

     (((3))) (2) 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))) (3) Each dental-related procedure described under this section is subject to the coverage limitations listed in chapter 388-535 WAC.

     (((5))) (4) The department does not cover any dental-related services not listed in this section for ((clients eligible under the GA-U or ADATSA program)) a disability lifeline client or an ADATSA client who is twenty-one years of age or older, including any type of removable prosthesis (denture).

[Statutory Authority: RCW 74.04.050, 74.08.090. 07-17-107, § 388-535-1065, filed 8/17/07, effective 9/17/07. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-041, § 388-535-1065, filed 3/1/07, effective 4/1/07. 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.]

     (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 documented in the client's record in accordance with chapter 388-502 WAC;

     (e) Are within 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) The department covers nonemergent dental-related services performed in a hospital or an ambulatory surgical center for:

     (a) Clients eight years of age and younger;

     (b) Clients from nine to twenty years of age only on a case-by-case basis and when the services are prior authorized; and

     (c) Clients of the division of developmental disabilities according to WAC 388-535-1099.

     (3) To be eligible for payment, dental-related services performed in a hospital or an ambulatory surgery center must be listed in the department's current published outpatient fee schedule or ambulatory surgical center fee schedule. The claim must be billed with the correct procedure code for the site of service.

     (4) Under the early periodic screening and diagnostic treatment (EPSDT) program, clients ((ages)) twenty years of age and younger may be eligible for dental-related services listed as noncovered.

     (((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))) (5) 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.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1079, filed 3/1/07, effective 4/1/07.]

     (1) Clinical oral evaluations. The department covers:

     (a) Oral health evaluations and assessments.

     (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:

     (i) Original radiographs to be retained by the provider as part of the client's dental record((,)); and

     (ii) Duplicate radiographs to be submitted:

     (A) With requests for prior authorization ((requests, or)); and

     (B) When the department requests 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. The department does not cover occlusal intraoral radiographs for clients of the division of developmental disabilities who are twenty-one years of age and older. Documentation supporting the medical necessity for these must be included in the client's record.

     (f) Covers a maximum of four 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))) (h) 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))) (i) Covers cephalometric film((:

     (i))), only on a case-by-case basis and when prior authorized. The department does not cover cephalometric film for clients of the division of developmental disabilities who are twenty-one years of age and older. For ((orthodontics)) orthodontic services, ((as described in)) see chapter 388-535A WAC((; or

     (ii) Only on a case-by-case basis and when prior authorized)).

     (((k))) (j) Covers radiographs not listed as covered in this subsection, only on a case-by-case basis and when prior authorized.

     (((l))) (k) 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) Covers 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) Covers diagnostic casts other than those included in an orthodontic case study, on a case-by-case basis, and when requested by the department.

     (c) Does not cover the tests and examinations in (a) and (b) of this subsection for clients of the division of developmental disabilities who are twenty-one years of age and older.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1080, filed 3/1/07, effective 4/1/07. 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 as follows. 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 twenty)).

     (b) Is limited to once every:

     (i) Six months for clients eighteen years of age and younger; and

     (ii) Twelve months for clients from nineteen to twenty years of age.

     (c) Is covered only when the service is performed:

     (i) Six months after periodontal scaling and root planing, or periodontal maintenance services, for clients ((ages)) from thirteen ((through twenty.

     (c))) to eighteen years of age; and

     (ii) Twelve months after periodontal scaling and root planing, periodontal maintenance services, for clients from nineteen to twenty years of age.

     (d) Is covered only when not performed on the same date of service as periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty.

     (((d))) (e) Is covered for clients of the division of developmental disabilities according to (a), (c) and (d) of this subsection and WAC 388-535-1099.

     (2) Topical fluoride treatment. The department covers:

     (a) Fluoride ((varnish,)) rinse, foam or gel for clients ((ages)) six years of age and younger, up to three times within a twelve-month period.

     (b) Fluoride ((varnish,)) rinse, foam or gel for clients ((ages)) from seven ((through)) to eighteen years of age, 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)) from nineteen ((through)) to twenty years of age, 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 years of age and younger.

     (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.

     (f) Oral hygiene instruction only for clients of the division of developmental disabilities who are seven years of age and younger.

     (4) Sealants. The department covers:

     (a) Sealants only when used on a mechanically and/or chemically prepared enamel surface.

     (b) Sealants once per tooth:

     (i) In a three-year period for clients ((through age)) eighteen years of age and younger; and

     (ii) In a two-year period for clients any age of the division of developmental disabilities according to WAC 388-535-1099.

     (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 on noncarious teeth or teeth with incipient caries.

     (e) Sealants only when placed on a tooth with no preexisting 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) Covers fixed unilateral or fixed bilateral space maintainers for clients ((through age)) eighteen((.

     (b))) years of age and younger, subject to the following:

     (i) Only one space maintainer is covered per quadrant.

     (((c))) (ii) Space maintainers are covered only for missing primary molars A, B, I, J, K, L, S, and T.

     (((d))) (iii) Replacement space maintainers are covered only on a case-by-case basis and when prior authorized.

     (b) Covers removal of fixed space maintainers for clients eighteen years of age and younger.

     (c) Does not cover space maintainers or removal of space maintainers for clients nineteen years of age and older, including clients of the division of developmental disabilities who are nineteen years of age and older.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1082, filed 3/1/07, effective 4/1/07.]

     (1) ((Restorative/operative procedures. The department covers restorative/operative procedures performed in a hospital or an ambulatory surgical center for:

     (a) Clients ages eight and younger;

     (b) Clients ages nine through twenty only on a case-by-case basis and when prior authorized; and

     (c) Clients of the division of developmental disabilities according to WAC 388-535-1099.

     (2))) Amalgam restorations for primary and permanent teeth. The department considers:

     (a) Tooth preparation, all adhesives (including amalgam bonding agents), liners, bases, and polishing as part of the amalgam restoration.

     (b) The occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of the amalgam restoration.

     (c) Buccal or lingual surface amalgam restorations, regardless of size or extension, as a one surface restoration. The department covers one buccal and one lingual surface per tooth.

     (d) Multiple amalgam restorations of fissures and grooves of the occlusal surface of the same tooth as a one surface restoration.

     (e) Amalgam restorations placed within six months of a crown preparation by the same provider or clinic to be included in the payment for the crown.

     (((3))) (2) Amalgam restorations for primary posterior teeth only. The department covers amalgam restorations for a maximum of two surfaces for a primary first molar and maximum of three surfaces for a primary second molar. (See subsection (9)(c) of this section for restorations for a primary posterior tooth requiring additional surfaces.) The department does not pay for additional amalgam restorations.

     (((4))) (3) Amalgam restorations for permanent posterior teeth only. The department:

     (a) Covers two occlusal amalgam restorations for teeth one, two, three fourteen, fifteen, and sixteen, if the restorations are anatomically separated by sound tooth structure.

     (b) 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.

     (c) 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 (a) of this subsection).

     (d) Does not pay for replacement of amalgam restoration on permanent posterior 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.

     (((5))) (4) Resin-based composite restorations for primary and 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 dentoenamel junction (DEJ) to be sealants (see WAC 388-535-1082(4) for sealants coverage).

     (e) Considers multiple preventive restorative resin, flowable composite resin, or resin-based composites 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) when performed on posterior teeth or the incisal surface of anterior teeth.

     (g) Considers resin-based composite restorations placed within six months of a crown preparation by the same provider or clinic to be included in the payment for the crown.

     (((6))) (5) Resin-based composite restorations for primary teeth only. The department covers:

     (a) Resin-based composite restorations for a maximum of three surfaces for a primary anterior tooth (see subsection (((9)(b))) (8)(b) of this section for restorations for a primary anterior tooth requiring a four or more surface restoration). The department does not pay for additional composite or amalgam restorations on the same tooth after three surfaces.

     (b) Resin-based composite restorations for a maximum of two surfaces for a primary first molar and a maximum of three surfaces for a primary second molar. (See subsection (9)(c) of this subsection for restorations for a primary posterior tooth requiring additional surfaces.) The department does not pay for additional composite restorations on the same tooth.

     (c) Glass ((ionimer)) ionomer restorations only for primary teeth, and only for clients ((ages)) five years of age and younger. The department does not cover glass ionomer restorations for clients of the division of developmental disabilities who are five years of age and older. The department pays for these restorations as a one surface resin-based composite restoration.

     (((7))) (6) Resin-based composite restorations for permanent teeth only. The department covers:

     (a) Two occlusal resin-based composite restorations for teeth one, two, fourteen, fifteen, and sixteen if the restorations are anatomically separated by sound tooth structure.

     (b) 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.

     (c) 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 (a) of this subsection).

     (d) 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.

     (e) Replacement of resin-based composite restoration on permanent teeth within a two-year period only if the restoration has an additional adjoining carious surface. The department pays the replacement restoration as a one multi-surface restoration. The client's record must include radiographs and documentation supporting the medical necessity for the replacement restoration.

     (((8))) (7) Crowns. The department:

     (a) Covers the following crowns once every five years, per tooth, for permanent anterior teeth for clients ((ages)) from twelve ((through)) to twenty years of age when the crowns meet prior authorization criteria in WAC 388-535-1220 and the provider follows the prior authorization requirements in (d) of this subsection:

     (i) Porcelain/ceramic crowns to include all porcelains, glasses, glass-ceramic, and porcelain fused to metal crowns; and

     (ii) Resin crowns and resin metal crowns to include any resin-based composite, fiber, or ceramic reinforced polymer compound.

     (b) ((Covers full coverage metal crowns once every five years, per tooth, for permanent posterior teeth to include high noble, titanium, titanium alloys, noble, and predominantly base metal crowns for clients ages eighteen through twenty when they meet prior authorization criteria and the provider follows the prior authorization requirements in (d) and (e) of this subsection.

     (c))) Considers the following to be included in the payment for a crown:

     (i) Tooth and soft tissue preparation;

     (ii) Amalgam and resin-based composite restoration, or any other restorative material placed within six months of the crown preparation. Exception: The department covers a one surface restoration on an endodontically treated tooth, or a core buildup or cast post and core;

     (iii) Temporaries, including but not limited to, temporary restoration, temporary crown, provisional crown, temporary prefabricated stainless steel crown, ion crown, or acrylic crown;

     (iv) Packing cord placement and removal;

     (v) Diagnostic or final impressions;

     (vi) Crown seating (placement), including cementing and insulating bases;

     (vii) Occlusal adjustment of crown or opposing tooth or teeth; and

     (viii) Local anesthesia.

     (((d))) (c) Requires the provider to submit the following with each prior authorization request:

     (i) Radiographs to assess all remaining teeth;

     (ii) Documentation and identification of all missing teeth;

     (iii) Caries diagnosis and treatment plan for all remaining teeth, including a caries control plan for clients with rampant caries;

     (iv) Pre- and post-endodontic treatment radiographs for requests on endodontically treated teeth; and

     (v) Documentation supporting a five-year prognosis that the client will retain the tooth or crown if the tooth is crowned.

     (((e))) (d) Requires a provider to bill for a crown only after delivery and seating of the crown, not at the impression date.

     (((9))) (8) Other restorative services. The department covers the following restorative services:

     (a) All recementations of permanent indirect crowns only for clients from twelve to twenty years of age.

     (b) Prefabricated stainless steel crowns with resin window, resin-based composite crowns, prefabricated esthetic coated stainless steel crowns, and fabricated resin crowns for primary anterior teeth once every three years:

     (i) Only for clients from twelve to twenty years of age; and

     (ii) Without prior authorization if the tooth requires a four or more surface restoration.

     (c) Prefabricated stainless steel crowns for primary posterior teeth once every three years without prior authorization if:

     (i) Decay involves three or more surfaces for a primary first molar;

     (ii) Decay involves four or more surfaces for a primary second molar; or

     (iii) The tooth had a pulpotomy.

     (d) Prefabricated stainless steel crowns for permanent posterior teeth once every three years when prior authorized.

     (e) Prefabricated stainless steel crowns for clients of the division of developmental disabilities without prior authorization according to WAC 388-535-1099.

     (f) Core buildup, including pins, only on permanent teeth, only for clients twenty years of age and younger, and only when prior authorized at the same time as the crown prior authorization.

     (g) Cast post and core or prefabricated post and core, only on permanent teeth, only for clients twenty years of age and younger, and only when prior authorized at the same time as the crown prior authorization.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1084, filed 3/1/07, effective 4/1/07.]

     Reviser's note: The typographical 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.
AMENDATORY SECTION(Amending WSR 07-06-042, filed 3/1/07, effective 4/1/07)

WAC 388-535-1086   Covered dental-related services for clients ((through age)) twenty years of age and younger, and for clients of the division of developmental disabilities--Endodontic services.   Subject to coverage limitations and client-age requirements identified for a specific service, the department covers ((medically necessary)) the dental-related endodontic services((, subject to the coverage limitations listed, for)) listed in this section that are provided to clients ((through age)) twenty ((as follows:)) years of age and younger, and to clients of the division of developmental disabilities. All coverage limitations and age requirements apply to clients of the division of developmental disabilities, unless otherwise stated.

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

     (2) Pulpotomy. The department covers:

     (a) Therapeutic pulpotomy on primary posterior teeth only((; and)) for clients twenty years of age and younger. The department does not cover therapeutic pulpotomy on primary posterior teeth for clients of the division of developmental disabilities who are twenty-one years of age and older.

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

     (3) Endodontic treatment. The department:

     (a) Covers endodontic treatment with resorbable material for primary maxillary incisor teeth D, E, F, and G, if the entire root is present at treatment.

     (b) Covers endodontic treatment for permanent anterior, bicuspid, and molar teeth, excluding teeth one, sixteen, seventeen, and thirty-two for clients twenty years of age and younger. The department does not cover endodontic treatment for these teeth for clients of the division of developmental disabilities who are twenty-one years of age and older, except as stated in (c) of this subsection.

     (c) Covers endodontic treatment only for permanent anterior teeth for clients of the division of developmental disabilities who are twenty-one years of age and older.

     (d) 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.

     (((d))) (e) 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.

     (((e))) (f) 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 anterior, bicuspid, and molar teeth, excluding teeth one, sixteen, seventeen, and thirty-two.

     (((f))) (g) 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.

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

     (((h))) (i) Covers apexification for apical closures for anterior permanent teeth only on a case-by-case basis and when prior authorized. Apexification is limited to the initial visit and three interim treatment visits for clients twenty years of age and younger. The department does not cover apexification film for clients of the division of developmental disabilities who are twenty-one years of age and older.

     (((i))) (j) Covers apicoectomy and a retrograde fill for anterior teeth only for clients twenty years of age and younger. The department does not cover apicoectomy or a retrograde fill for clients of the division of developmental disabilities who are twenty-one years of age and older.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1086, filed 3/1/07, effective 4/1/07.]

     (1) Surgical periodontal services. The department covers the following surgical periodontal services, including all postoperative care:

     (a) Gingivectomy/gingivoplasty only on a case-by-case basis and when prior authorized; and

     (b) Gingivectomy/gingivoplasty for clients of the division of developmental disabilities according to WAC 388-535-1099.

     (2) Nonsurgical periodontal services. The department:

     (a) Covers periodontal scaling and root planing for clients from thirteen to eighteen years of age, once per quadrant, per client in a two-year period on a case-by-case basis, when prior authorized ((for clients ages thirteen through eighteen)), and only 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) Covers periodontal scaling and root planing once per quadrant, per client, in a two-year period for clients ((ages)) from nineteen ((through)) to twenty years of age. Criteria in (a)(i) through (iv) of this subsection must be met.

     (c) Considers ultrasonic scaling, gross scaling, or gross debridement to be included in the procedure and not a substitution for periodontal scaling and root planing.

     (d) 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.

     (e) 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 for clients from thirteen to eighteen years of age, once per client in a twelve-month period on a case-by-case basis, when prior authorized, ((for clients ages thirteen through eighteen,)) and only 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 twelve months from the date of completion of periodontal scaling and root planing, or surgical periodontal treatment.

     (b) Covers periodontal maintenance once per client in a twelve month period for clients ages nineteen through twenty. Criteria in (a)(i) through (iv) of this subsection must be met.

     (c) Covers periodontal maintenance only if performed on a different date of service as prophylaxis, periodontal scaling and root planing, gingivectomy, or gingivoplasty.

     (d) Covers periodontal maintenance for clients of the division of developmental disabilities according to WAC 388-535-1099.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1088, filed 3/1/07, effective 4/1/07.]

     (1) Prosthodontics. The department:

     (a) Requires prior authorization for all removable prosthodontic and prosthodontic-related procedures, except as stated in (c)(ii)(B) of this subsection. Prior authorization requests must meet the criteria in WAC 388-535-1220. In addition, the department requires the dental provider to submit:

     (i) Appropriate and diagnostic radiographs of all remaining teeth.

     (ii) A dental record which identifies:

     (A) All missing teeth for both arches;

     (B) Teeth that are to be extracted; and

     (C) Dental and periodontal services completed on all remaining teeth.

     (iii) A prescription written by a dentist when a denturist's prior authorization request is for an immediate denture or a cast metal partial denture.

     (b) Covers complete dentures, as follows:

     (i) A complete denture, including an ((immediate denture or)) overdenture, is covered when prior authorized.

     (ii) An immediate denture for clients twenty years of age and younger when prior authorized.

     (iii) Three-month post-delivery care (e.g., adjustments, soft relines, and repairs) from the seat (placement) date of the complete denture, is considered part of the complete denture procedure and is not paid separately.

     (((iii))) (iv) Replacement of an immediate denture with a complete denture is covered if the complete denture is prior authorized at least six months after the seat date of the immediate denture.

     (((iv))) (v) Replacement of a complete denture or overdenture is covered only if prior authorized at least five years after the seat date of the complete denture or overdenture being replaced. The replacement denture must be prior authorized.

     (vi) Complete dentures for clients of the division of developmental disabilities who are twenty-one years of age and older are limited to:

     (A) One initial maxillary complete denture and one initial mandibular complete denture per client, per the client's lifetime; and

     (B) One replacement maxillary complete denture and one replacement mandibular complete denture per client, per the client's lifetime.

     (c) Covers partial dentures, as follows:

     (i) A partial denture, including a resin ((or flexible base)) partial denture, is covered for anterior and posterior teeth when the partial denture meets the following department coverage 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 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 the remaining teeth.

     (ii) Prior authorization of partial dentures:

     (A) Is required for clients ((ages)) nine years of age and younger((; and)).

     (B) Is not required for clients ((ages)) from ten ((through)) to twenty years of age. Documentation supporting the medical necessity for the service must be included in the client's file.

     (C) Is required for clients of the division of developmental disabilities who are twenty-one years of age and older.

     (iii) Three-month post-delivery care (e.g., adjustments, soft relines, and repairs) from the seat date of the partial denture, is considered part of the partial denture procedure and is not paid separately.

     (iv) Replacement of a resin or flexible base denture is covered only if prior authorized at least three years after the seat date of the resin or flexible base partial denture being replaced. The replacement denture must be prior authorized and meet department coverage criteria in (c)(i) of this subsection.

     (d) Covers cast-metal framework partial dentures, as follows:

     (i) Cast-metal framework with resin-based partial dentures, including any conventional clasps, rests, and teeth, are covered for clients ((ages)) from eighteen ((through)) to twenty years of age:

     (A) Only once in a five-year period((,));

     (B) On a case-by-case basis((,));

     (C) When prior authorized; and

     (D) When department coverage criteria listed in subsection (d)(v) of this subsection are met.

     (ii) Cast-metal framework partial dentures for clients ages seventeen and younger are not covered.

     (iii) Cast-metal framework partial dentures are not covered for clients of the division of developmental disabilities who are twenty-one years of age and older.

     (iv) Three-month post-delivery care (e.g., adjustments, soft relines, and repairs) from the seat date of the cast metal partial denture is considered part of the partial denture procedure and is not paid separately.

     (((iv))) (v) Replacement of a cast metal framework partial denture is covered on a case-by-case basis and only if placed at least five years after the seat date of the partial denture being replaced. The replacement denture must be prior authorized and meet department coverage criteria listed in (d)(v) of this subsection.

     (((v))) (vi) 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; and

     (F) There is a five-year prognosis for the retention of the remaining teeth.

     (((vi))) (vii) The department may consider resin partial dentures as an alternative if the department determines the criteria for cast metal framework partial dentures listed in (d)(v) of this subsection are not met.

     (e) Requires a provider to bill for removable prosthetic procedures only after the seating of the prosthesis, not at the impression date. Refer to subsection (2)(e) and (f) for what the department may pay if the removable prosthesis is not delivered and inserted.

     (f) Requires a provider to submit the following with a prior authorization request for removable prosthetics for a client residing in an alternate living facility (ALF) as defined in WAC 388-513-1301 or in a nursing facility:

     (i) The client's medical diagnosis or 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 for treatment 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's published billing instructions.

     (g) Limits removable partial dentures to resin-based partial dentures for all clients residing in one of the facilities listed in (f) of this subsection. The department may consider cast metal partial dentures if the criteria in subsection (1)(d) 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 prosthodontics. The department covers:

     (a) Adjustments to complete and partial dentures three months after the date of delivery.

     (b) Repairs to complete and partial dentures, once in a twelve month period. The cost of repairs cannot exceed the cost of replacement. The department covers additional repairs on a case-by-case basis and when prior authorized.

     (c) 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 seating date. An additional reline or rebase may be covered for complete or cast-metal partial dentures on a case-by-case basis when prior authorized.

     (d) Up to two tissue conditionings for clients twenty years of age and younger, and only when performed within three months after the seating date.

     (e) Laboratory fees, subject to the following:

     (i) The department does not pay separately for laboratory or professional fees for complete and partial dentures; and

     (ii) The department may pay part of billed laboratory fees when the provider obtains prior authorization, and the client:

     (A) Is not eligible at the time of delivery of the prosthesis;

     (B) Moves from the state;

     (C) Cannot be located;

     (D) Does not participate in completing the complete, immediate, or partial dentures; or

     (E) Dies.

     (f) A provider must submit copies of laboratory prescriptions and receipts or invoices for each claim when billing for laboratory fees.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1090, filed 3/1/07, effective 4/1/07.]

     (1) Maxillofacial prosthetics are covered only on a case-by-case basis and when prior authorized; and

     (2) The department must pre-approve a provider qualified to furnish maxillofacial prosthetics.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1092, filed 3/1/07, effective 4/1/07.]

     (1) Oral and maxillofacial surgery services. The department:

     (a) Requires enrolled 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) Covers nonemergency oral surgery performed in a hospital or ambulatory surgery center only for:

     (i) Clients ((ages)) eight years of age and younger;

     (ii) Clients ((ages)) from nine ((through)) to twenty years of age only on a case-by-case basis and when prior authorized; and

     (iii) Clients any age of the division of developmental disabilities ((according to WAC 388-535-1099)).

     (d) Requires the client's dental record to include supporting documentation for each type of extraction or any other surgical procedure billed to the department. The documentation must include:

     (i) 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) Requires authorization for complicated surgical extractions.

     (g) Covers tooth reimplantation/stabilization of accidentally evulsed or displaced teeth for clients twenty years of age and younger.

     (h) Covers surgical extraction of unerupted teeth for clients twenty years of age and younger.

     (i) 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))) (j) Covers ((biopsy, as follows)) the following without prior authorization:

     (i) Biopsy of soft oral tissue ((or));

     (ii) Brush biopsy ((do not require prior authorization; and)) for clients twenty years of age and younger.

     (((ii))) (k) Requires providers to keep all biopsy reports or findings ((must be kept)) in the client's dental record.

     (((h))) (l) Covers alveoloplasty for clients twenty years of age and younger only on a case-by-case basis and when prior authorized. The department covers alveoplasty only when not performed in conjunction with extractions.

     (((i))) (m) Covers surgical excision of soft tissue lesions only on a case-by-case basis and when prior authorized.

     (((j))) (n) Covers only the following excisions of bone tissue in conjunction with placement of immediate, complete, or partial dentures for clients twenty years of age and younger 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 incisions. 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.

     (b) Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue for clients twenty years of age and younger when prior authorized. Documentation supporting the medical necessity for the service must be in the client's record.

     (c) Frenuloplasty/frenulectomy for clients ((through age)) six years of age and younger without prior authorization.

     (d) ((The department covers)) Frenuloplasty/frenulectomy for clients ((ages)) from seven ((through)) to twelve years of age only on a case-by-case and when prior authorized. Documentation supporting the medical necessity for the service must be in the client's record.

     (3) Occlusal orthotic devices. (Refer to WAC 388-535-1098 (5)(c) for occlusal guard coverage and limitations on coverage.) The department covers:

     (a) Occlusal orthotic devices for clients ((ages)) from twelve ((through)) to twenty years of age only on a case-by-case basis and when prior authorized.

     (b) An occlusal orthotic device only as a laboratory processed full arch appliance.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1094, filed 3/1/07, effective 4/1/07.]

     (2) The department does not cover orthodontic services for clients of the division of developmental disabilities who are twenty-one years of age and older.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1096, filed 3/1/07, effective 4/1/07.]

     (1) Adjunctive general services. The department:

     (a) Covers palliative (emergency) treatment, not to include pupal debridement (see WAC 388-535-1086 (2)(b)), for treatment of dental pain, for clients twenty years of age and younger, limited to once per day, per client, as follows:

     (i) The treatment must occur during limited evaluation appointments;

     (ii) A comprehensive description of the diagnosis and services provided must be documented in the client's record; and

     (iii) Appropriate radiographs must be in the client's record supporting the medical necessity of 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 conscious sedation, deep sedation, or general anesthesia, as follows:

     (i) The provider's current anesthesia permit must be on file with the department.

     (ii) ((For clients of the division of developmental disabilities, the services must be performed according to WAC 388-535-1099.

     (iii))) For clients ((ages)) eight years of age and younger, and for clients of the division of developmental disabilities, documentation supporting the medical necessity of the anesthesia service must be in the client's record.

     (((iv))) (iii) For clients ((ages)) from nine ((through)) to twenty years of age, deep sedation or general anesthesia services are covered on a case-by-case basis and when prior authorized, except for oral surgery services. Oral surgery services listed in WAC 388-535-1094 do not require prior authorization.

     (((v))) (iv) Prior authorization is not required for oral or parenteral conscious sedation for any dental service for clients twenty years of age and younger, and for clients of the division of developmental disabilities. Documentation supporting the medical necessity of the service must be in the client's record.

     (((vi))) (v) For clients ((ages)) from nine ((through)) to eighteen years of age who have a diagnosis of oral facial cleft, the department does not require prior authorization for deep sedation or general anesthesia services when the dental procedure is directly related to the oral facial cleft treatment.

     (((vii) For clients through age twenty, the)) (vi) A provider must bill anesthesia services using the CDT codes listed in the department's current published billing instructions.

     (d) Covers inhalation of nitrous oxide ((for clients through age twenty)), once per day.

     (e) Requires providers of oral or parenteral conscious sedation, deep 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, or nursing anesthesia regulations.

     (f) Pays for anesthesia services according to WAC 388-535-1350.

     (g) 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 only for:

     (a) Clients ages eight and younger.

     (b) Clients ages nine through twenty only on a case-by-case basis and when prior authorized.

     (c) 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, and not in combination with a surgical code unless the decision for surgery is a result of the visit.

     (c) Emergency office visits after regularly scheduled hours. The department limits payment to one emergency visit per day, per provider.

     (((4))) (3) Drugs and/or medicaments (pharmaceuticals). The department covers drugs and/or medicaments 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))) (4) Miscellaneous services. The department covers:

     (a) Behavior management when the assistance of one additional dental staff other than the dentist is required, for:

     (i) Clients ((ages)) eight years of age and younger;

     (ii) Clients ((ages)) from nine ((through)) to twenty years of age, only on a case-by-case basis and when prior authorized;

     (iii) Clients any age of the division of developmental disabilities ((according to WAC 388-535-1099)); and

     (iv) Clients who reside in an alternate living facility (ALF) as defined in WAC 388-513-1301 or in a nursing facility.

     (b) Treatment of post-surgical complications (e.g., dry socket). Documentation supporting the medical necessity of the service must be in the client's record.

     (c) Occlusal guards when medically necessary and prior authorized. (Refer to WAC 388-535-1094(3) for occlusal orthotic device coverage and coverage limitations.) The department covers:

     (i) An occlusal guard only for clients ((ages)) from twelve ((through)) to twenty years of age when the client has permanent dentition; and

     (ii) An occlusal guard only as a laboratory processed full arch appliance.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1098, filed 3/1/07, effective 4/1/07.]

     (1) Preventive services.

     (a) Dental prophylaxis. The department covers dental prophylaxis or periodontal maintenance up to three times in a twelve-month period (see subsection (3) of this section for limitations on periodontal scaling and root planing).

     (b) Topical fluoride treatment. The department covers topical fluoride varnish, rinse, foam or gel, up to three times within a twelve-month period.

     (c) Sealants. The department covers sealants:

     (i) Only when used on the occlusal surfaces of:

     (A) Primary teeth A, B, I, J, K, L, S, and T; or

     (B) Permanent teeth two, three, four, five, twelve, thirteen, fourteen, fifteen, eighteen, nineteen, twenty, twenty-one, twenty-eight, twenty-nine, thirty, and thirty-one.

     (ii) Once per tooth in a two-year period.

     (2) Crowns. The department covers stainless steel crowns every two years for the same tooth and only for primary molars and permanent premolars and molars, as follows:

     (a) For clients ages twenty and younger, the department does not require prior authorization for stainless steel crowns. Documentation supporting the medical necessity of the service must be in the client's record.

     (b) For clients ages twenty-one and older, the department requires prior authorization for stainless steel crowns.

     (3) Periodontic services.

     (a) Surgical periodontal services. The department covers:

     (i) Gingivectomy/gingivoplasty once every three years. Documentation supporting the medical necessity of the service must be in the client's record (e.g., drug induced gingival hyperplasia).

     (ii) Gingivectomy/gingivoplasty with periodontal scaling and root planing or periodontal maintenance when the services are performed:

     (A) In a hospital or ambulatory surgical center; or

     (B) For clients under conscious sedation, deep sedation, or general anesthesia.

     (b) Nonsurgical periodontal services. The department covers:

     (i) Periodontal scaling and root planing, up to two times per quadrant in a twelve-month period.

     (ii) Periodontal scaling (four quadrants) substitutes for an eligible periodontal maintenance or oral prophylaxis, twice in a twelve-month period.

     (4) Adjunctive general services.

     (((a) Adjunctive general services.)) The department covers:

     (((i))) (a) Oral parenteral conscious sedation, deep sedation, or general anesthesia for any dental services performed in a dental office or clinic. Documentation supporting the medical necessity must be in the client's record.

     (((ii))) (b) Sedations services according to WAC 388-535-1098 (1)(c) and (e).

     (b) Nonemergency dental services. The department covers nonemergency dental services performed in a hospital or an ambulatory surgical center for services listed as covered in WAC 388-535-1082, 388-535-1084, 388-535-1086, 388-535-1088, and 388-535-1094. Documentation supporting the medical necessity of the service must be included in the client's record.

     (5) Miscellaneous services--Behavior management. The department covers behavior management provided in dental offices or dental clinics ((for clients of any age)). Documentation supporting the medical necessity of the service must be included in the client's record.

     (6) Billing requirements for clients of the division of developmental disabilities who are twenty-one years of age and older. To be paid, each claim billed for clients twenty-one years of age and older:

     (a) Requires an expedited authorization number to indicate that the client is a client of the division of developmental disabilities; and

     (b) Must meet prior authorization requirements for the service(s), if required.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1099, filed 3/1/07, effective 4/1/07.]

     Reviser's note: The typographical 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.
AMENDATORY SECTION(Amending WSR 07-06-042, filed 3/1/07, effective 4/1/07)

WAC 388-535-1100   Dental-related services not covered ((for clients through age twenty)).   (1) The department does not cover the following ((for clients through age twenty)):

     (a) The dental-related services described in subsection (2) of this section unless the services are covered under the early periodic screening, diagnosis and treatment (EPSDT) program. See WAC 388-534-0100 for information about the EPSDT program.

     (b) Any service specifically excluded by statute.

     (c) More costly services when less costly, equally effective services as determined by the department are available.

     (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 current published documents.

     (2) The department does not cover dental-related services listed under the following categories of service ((for clients through age twenty)) (see subsection (1)(a) of this section for services provided under the EPSDT program):

     (a) Diagnostic services. The department does not cover:

     (i) Extraoral radiographs.

     (ii) Comprehensive periodontal evaluations.

     (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) Removable space maintainers of any type.

     (iv) Sealants placed on a tooth with the same-day occlusal restoration, preexisting occlusal restoration, or a tooth with occlusal decay.

     (v) Space maintainers for clients ((ages)) nineteen ((through twenty)) years of age and older.

     (c) Restorative services. The department does not cover:

     (i) Restorations for wear on any surface of any tooth without evidence of decay through the dentoenamel junction (DEJ) or on the root surface;

     (ii) Gold foil restorations.

     (((ii))) (iii) Metallic, resin-based composite, or porcelain/ceramic inlay/onlay restorations.

     (((iii))) (iv) Preventive restorations.

     (v) Crowns for cosmetic purposes (e.g., peg laterals and tetracycline staining).

     (((iv))) (vi) Permanent crowns for ((third molars one, sixteen, seventeen, and thirty-two)) bicuspids or molar teeth.

     (((v))) (vii) Temporary or provisional crowns (including ion crowns).

     (((vi))) (viii) Labial veneer resin or porcelain laminate restorations.

     (((vii))) (ix) Sedative fillings.

     (x) Any type of coping.

     (((viii))) (xi) Crown repairs.

     (((ix))) (xii) 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) Any endodontic therapy on primary teeth, except as described in WAC 388-535-1086 (3)(a).

     (((ii))) (iii) Apexification/recalcification for root resorption of permanent anterior teeth.

     (((iii))) (iv) Any apexification/recalcification procedures for bicuspid or molar teeth.

     (((iv))) (v) Any apicoectomy/periradicular services for bicuspid or molar teeth.

     (((v))) (vi) Any surgical endodontic procedures including, but not limited to, retrograde fillings (except for anterior teeth), root amputation, reimplantation, and hemisections.

     (e) Periodontic services. The department does not cover:

     (i) Surgical periodontal services including, but not limited to:

     (A) Gingival flap procedures.

     (B) Clinical crown lengthening.

     (C) 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.

     (H) Distal or proximal wedge procedures.

     (ii) Nonsurgical periodontal services including, but not limited to:

     (A) Intracoronal or extracoronal provisional splinting.

     (B) Full mouth or quadrant debridement.

     (C) Localized delivery of chemotherapeutic agents.

     (D) Any other type of nonsurgical periodontal service.

     (f) Removable prosthodontics. The department does not cover:

     (i) Removable unilateral partial dentures.

     (ii) Any interim complete or partial dentures.

     (iii) Flexible base partial dentures.

     (iv) Any type of permanent soft reline (e.g., molloplast).

     (v) Precision attachments.

     (((iv))) (vi) Replacement of replaceable parts for semi-precision or precision attachments.

     (g) Implant services. The department does not cover:

     (i) Any type of 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 (g)(i) of this subsection.

     (iii) The removal of any implant as described in (g)(i) of this subsection.

     (h) Fixed prosthodontics. The department does not cover:

     (i) Any type of fixed partial denture pontic or fixed partial denture retainer.

     (ii) Any type of precision attachment, stress breaker, connector bar, coping, cast post, or any other type of fixed attachment or prosthesis.

     (i) Oral and maxillofacial surgery. The department does not cover:

     (i) Any oral surgery service not listed in WAC 388-535-1094.

     (ii) 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.

     (j) Adjunctive general services. The department does not cover:

     (i) Anesthesia, including, but not limited to:

     (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) Medication for oral sedation, or therapeutic intramuscular (IM) drug injections, including antibiotic and injection of sedative.

     (E) Application of any type of desensitizing medicament or resin.

     (ii) Other general services including, but not limited to:

     (A) Fabrication of an athletic mouthguard.

     (B) Occlusion analysis.

     (C) Occlusal adjustment, tooth or restoration adjustment or smoothing, or odontoplasties.

     (D) Enamel microabrasion.

     (E) Dental supplies such as 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) Fees for no-show, cancelled, or late arrival appointments.

     (M) Service charges of any type, including fees to create or copy charts.

     (N) Office supplies used in conjunction with an office visit.

     (O) Teeth whitening services or bleaching, or materials used in whitening or bleaching.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1100, filed 3/1/07, effective 4/1/07. 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, § 388-535-1100, 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, § 388-535-1100, 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, § 388-535-1100, 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), § 388-535-1100, filed 12/6/95, effective 1/6/96.]

     (2) 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 Association (ADA) claim form, which may be obtained by writing to the American Dental Association, 211 East Chicago Avenue, Chicago, Illinois 60611)) DSHS form 13-835, available on the department's website.

     (3) The department may request additional information as follows:

     (a) Additional radiographs (X rays) (refer to WAC 388-535-1080(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 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1220, filed 3/1/07, effective 4/1/07. 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, § 388-535-1220, 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, § 388-535-1220, 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, § 388-535-1220, filed 3/10/99, effective 4/10/99.]

     (1) For covered dental-related services provided to eligible clients, ((MAA)) the department pays dentists and other eligible providers on a fee-for-service or contractual basis, subject to the exceptions and restrictions listed under WAC 388-535-1100 and 388-535-1400.

     (2) ((MAA)) The department sets maximum allowable fees for dental services ((provided to children)) as follows:

     (a) ((MAA's)) The department's historical reimbursement rates for various procedures are compared to usual and customary charges.

     (b) ((MAA)) The department consults with representatives of the provider community to identify program areas and concerns that need to be addressed.

     (c) ((MAA)) The department consults with dental experts and public health professionals to identify and prioritize dental services and procedures for their effectiveness in improving or promoting ((children's)) dental health.

     (d) Legislatively authorized vendor rate increases and/or earmarked appropriations for ((children's)) dental services are allocated to specific procedures based on the priorities identified in (c) of this subsection and considerations of access to services.

     (e) Larger percentage increases may be given to those procedures which have been identified as most effective in improving or promoting ((children's)) dental health.

     (f) Budget-neutral rate adjustments are made as appropriate based on the department's evaluation of utilization trends, effectiveness of interventions, and access issues.

     (3) ((MAA)) The department reimburses dental general anesthesia services for eligible clients on the basis of base anesthesia units plus time. Payment for dental general anesthesia is calculated as follows:

     (a) Dental procedures are assigned an anesthesia base unit of five;

     (b) Fifteen minutes constitute one unit of time. When a dental procedure requiring dental general anesthesia results in multiple time units and a remainder (less than fifteen minutes), the remainder or fraction is considered as one time unit;

     (c) Time units are added to the anesthesia base unit of five and multiplied by the anesthesia conversion factor;

     (d) The formula for determining payment for dental general anesthesia is: (5.0 base anesthesia units + time units) x conversion factor = payment.

     (4) When billing for anesthesia, the provider must show the actual beginning and ending times on the claim. Anesthesia time begins when the provider starts to physically prepare the client for the induction of anesthesia in the operating room area (or its equivalent), and ends when the provider is no longer in constant attendance (i.e., when the client can be safely placed under postoperative supervision).

     (5) ((MAA)) The department pays eligible providers listed in WAC 388-535-1070 for conscious sedation with parenteral and multiple oral agents, or for general anesthesia when the provider meets the criteria in this chapter and other applicable WAC.

     (6) Dental hygienists who have a contract with ((MAA)) the department are paid at the same rate as dentists who have a contract with ((MAA)) the department, for services allowed under The Dental Hygienist Practice Act.

     (7) Licensed denturists who have a contract with ((MAA)) the department are paid at the same rate as dentists who have a contract with ((MAA)) the department, for providing dentures and partials.

     (8) ((MAA)) The department makes fee schedule changes whenever the legislature authorizes vendor rate increases or decreases.

     (9) ((MAA)) The department may adjust maximum allowable fees to reflect changes in services or procedure code descriptions.

     (10) ((MAA)) The department does not pay separately for chart or record setup, or for completion of reports, forms, or charting. The fees for these services are included in ((MAA's)) the department's reimbursement for comprehensive oral evaluations or limited oral evaluations.

[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, § 388-535-1350, 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, § 388-535-1350, 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, § 388-535-1350, 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), § 388-535-1350, filed 12/6/95, effective 1/6/96.]

     (2) Participating providers must bill ((MAA)) the department their usual and customary fees.

     (3) Payment for dental services is based on ((MAA's)) the department's schedule of maximum allowances. Fees listed in the ((MAA)) department's fee schedule are the maximum allowable fees.

     (4) ((MAA)) The department pays the provider the lesser of the billed charge (usual and customary fee) or ((MAA's)) the department's maximum allowable fee.

     (5) ((MAA)) The department pays "by report" on a case-by-case basis, for a covered service that does not have a set fee.

     (6) Participating providers must bill a client according to WAC 388-502-0160, unless otherwise specified in this chapter.

     (7) If the client's eligibility for dental services ends before the conclusion of the dental treatment, payment for any remaining treatment is the client's responsibility. The exception to this is dentures and partial dentures as described in WAC 388-535-1240 and 388-535-1290.

[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, § 388-535-1400, 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, § 388-535-1400, 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, § 388-535-1400, 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), § 388-535-1400, filed 12/6/95, effective 1/6/96.]

[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, § 388-535-1450, 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, § 388-535-1450, 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, § 388-535-1450, 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), § 388-535-1450, filed 12/6/95, effective 1/6/96.]

[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, § 388-535-1500, 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, § 388-535-1500, 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), § 388-535-1500, filed 12/6/95, effective 1/6/96.]

     The following sections of the Washington Administrative Code are repealed:

WAC 388-535-1247	Dental-related services for clients age twenty-one and older -- General.
WAC 388-535-1255	Covered dental-related services -- Adults.
WAC 388-535-1257	Covered dental-related services for clients age twenty-one and older -- Preventive services.
WAC 388-535-1259	Covered dental-related services for clients age twenty-one and older -- Restorative services.
WAC 388-535-1261	Covered dental-related services for clients age twenty-one and older -- Endodontic services.
WAC 388-535-1263	Covered dental-related services for clients age twenty-one and older -- Periodontic services.
WAC 388-535-1266	Covered dental-related services for clients age twenty-one and older -- Prosthodontics (removable).
WAC 388-535-1267	Covered dental-related services for clients age twenty-one and older -- Oral and maxillofacial surgery services.
WAC 388-535-1269	Covered dental-related services for clients age twenty-one and older -- Adjunctive general services.
WAC 388-535-1271	Dental-related services not covered for clients age twenty-one and older.
WAC 388-535-1280	Obtaining prior authorization for dental-related services for clients age twenty-one and older.

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