Alaska Administrative Code
Title 7 - Health and Social Services
Part 8 - Medicaid Coverage and Payment
Chapter 110 - Medicaid Coverage; Professional Services
Article 3 - Dental Services
7 AAC 110.150 - Dental services for recipients under 21 years of age

Universal Citation: 7 AK Admin Code 110.150

Current through November 28, 2024

(a) Except as provided in 7 AAC 110.200(3), the department will pay for the services identified in the Fee Schedule: Dental Services for Children, adopted by reference in 7 AAC 160.900, as follows, provided to a recipient under 21 years of age:

(1) periodic oral evaluation not more than two times per calendar year, limited oral evaluation not more than two times per calendar year, and comprehensive oral evaluation not more than two times per calendar year; panoramic radiographs not more than one time per calendar year and other dental radiographs as necessary for dental care;

(2) preventive care, as follows:
(A) prophylaxis, limited to necessary scaling, polishing, and instructions on oral hygiene and diet, not more than two times per calendar year;

(B) topical application of fluoride not more than four times per calendar year, or topical fluoride varnish not more than four times per calendar year, or a combination of topical application of fluoride and fluoride varnish not more than four times per calendar year;

(C) sealants, limited to one time per tooth per calendar year; and

(D) space management therapy restricted to posterior teeth; the department will pay for a primary teeth space maintainer only if a significant risk exists of detrimental drifting occurring before the permanent tooth erupts and for a permanent teeth space maintainer only if prosthodontic treatment is not applicable;

(3) restorative care for the treatment of decayed or fractured teeth, including amalgams and resins, and crowns if the tooth cannot be restored with amalgams or resin; under this paragraph,
(A) a claim submitted for up to two crowns in a single day must be accompanied by medical justification;

(B) a provider must obtain prior authorization from the department for three or more crowns in a single day or four or more crowns in a 12-month period;

(C) all surfaces restored on a single tooth on the same day are considered connected; therefore, payment is limited to one single or multi surface restoration code per tooth per day;

(D) final restorations are limited to not more than five surfaces per tooth; tooth preparation, temporary restorations, sedative and cement bases, and local anesthesia are considered components of a complete restorative procedure and may not be billed separately; and

(E) the department will provide payment for a crown only upon seatment of the permanent crown, and for a partial or denture only upon seatment of the appliance; the department will not provide partial payment for incomplete or in-progress dental services;

(4) endodontics, with the following limitations:
(A) palliative and sedative treatments may not exceed two times per tooth before a definitive treatment;

(B) with respect to root canal therapy, tooth preparation, filling of the root canal, and follow-up are considered components of a complete root canal and may not be billed separately; and

(C) a separate claim may be made for pin retention and restoration, and may not exceed five surfaces per tooth;

(5) periodontics, including treatment of pain or acute infection of supporting tissues of the teeth, including gingivitis, periodontitis, and periodontal abscess;

(6) prosthodontics, including replacement of a complete or partial denture only if the existing denture is unusable and only once per five calendar years;

(7) oral surgery; under this paragraph, the following services are covered:
(A) extractions; under this subparagraph,
(i) a claim submitted for up to two extractions in a single day to alleviate immediate pain or infection must be accompanied by medical justification;

(ii) a provider must obtain prior authorization from the department for three or more extractions in a single day or four or more extractions in a 12-month period to alleviate immediate pain or infection; and

(iii) a provider must obtain prior authorization from the department for an extraction that is required for a reason other than to alleviate immediate pain or infection;

(B) local anesthesia, materials, and routine postoperative care are considered components of a complete surgical procedure and may not be billed separately;

(8) anesthesia and sedation in accordance with 7 AAC 110.155 and necessary for dental services covered under this section;

(9) professional consultation, if medically necessary or if requested by the department.

(b) Except as provided in 7 AAC 110.200(3), the department will not pay for the following dental services for recipients under 21 years of age:

(1) dental services not identified in the Fee Schedule: Dental Services for Children, adopted by reference in 7 AAC 160.900;

(2) behavior management in conjunction with any services covered under 7 AAC 110.155;

(3) indirect pulp capping;

(4) endodontic apical surgery and retrograde fillings;

(5) immediate, interim, and temporary dentures;

(6) dental implant and implant-related dental services;

(7) inlays, overlays, and three-fourth crowns;

(8) restoration of etched enamel or deep grooves without obvious dentin involvement;

(9) space maintainers for anterior teeth;

(10) tobacco counseling; tobacco counseling is considered a component of periodic and comprehensive evaluations and may not be billed separately;

(11) denture characterization and personalization, and precision attachments;

(12) experimental dental procedures;

(13) local anesthesia; local anesthesia is considered a component of covered dental procedures and may not be billed separately;

(14) anesthesia or sedation in conjunction with a noncovered service.

Authority:AS 47.05.010

AS 47.07.030

AS 47.07.040

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