Code of Colorado Regulations
2505 - Department of Health Care Policy and Financing
2505 - Medical Services Board (Volume 8; Medical Assistance, Children's Health Plan)
10 CCR 2505-10-8.200 - MEDICAL ASSISTANCE - SECTION 8.200 Physician Services, Dental, Vision Services, Medicaid Managed Care Program, EPSDT
Section 10 CCR 2505-10-8.202 - DENTAL SERVICES FOR CHILDREN

Universal Citation: 2505 CO Code Regs 10 CCR 2505-10-8.202

Current through Register Vol. 47, No. 5, March 10, 2024

8.202.1 DEFINITIONS

Apexication is a method of inducing a calcified barrier at the apex of a nonvital tooth with incomplete root formation.

Apexogenesis refers to a vital pulp therapy procedure performed to encourage physiological development and formation of the root end.

Child Client means an individual who is age 20 years or under and eligible for medical assistance benefits.

Comprehensive Oral Evaluation means a thorough evaluation and documentation of a client's dental and medical history to include extra-oral and intra-oral hard and soft tissues, dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, and oral cancer screening, as defined by the Current Dental Terminology (CDT) (2014).

Comprehensive Periodontal Evaluation means the procedure that is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the patient's dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation, as defined by the Current Dental Terminology (CDT) (2014).

Dental Caries is a common chronic infectious transmissible disease resulting from tooth-adherent specific bacteria that metabolize sugars to produce acid which demineralizes tooth structure over time (tooth decay).

Dental professional means licensed dentist or dental hygienist enrolled with Colorado Medicaid.

Detailed and Extensive Oral Evaluation- Problem Focused, By Report means a detailed and extensive problem focused evaluation entails extensive diagnostic and cognitive modalities based on the findings of a comprehensive oral evaluation. Integration of more extensive diagnostic modalities to develop a treatment plan for a specific problem is required. The condition requiring this type of evaluation should be described and documented. Examples of conditions requiring this type of evaluation may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain of unknown origin, conditions requiring multi-disciplinary consultation, etc., as defined by the Current Dental Terminology (CDT) (2014).

Diagnostic Imaging means a visual display of structural or functional patterns for the purpose of diagnostic evaluation, as defined by the Current Dental Terminology (CDT) (2014).

Early, Periodic Screening, Diagnosis and Treatment (EPSDT) Services means services that are available to clients 20 and under which are determined to be medically necessary and offered through the State Plan even if not available to other eligibility categories.

Endodontic services means services which are concerned with the morphology, physiology and pathology of the human dental pulp and periradicular tissues.

Emergency Services means the need for immediate intervention by a physician, osteopath or dental professional to stabilize an oral cavity condition.

Evaluation means a patient assessment that includes gathering of information through interview, observation, examination, and use of specific tests to diagnose existing conditions, as defined by the Current Dental Terminology (CDT) (2014).

High Risk of Caries is indicated in Child Clients who present with demonstrable caries, a history of restorative treatment, dental plaque, and enamel demineralization; or Child Clients of mothers with a high caries rate, especially with untreated caries; or Child Clients who sleep with a bottle containing anything other than water, or who breastfeed throughout the night (at-will nursing); or Child Clients with special health care needs.

Immediate Intervention or Treatment is when a patient presents with symptoms and/or complaints of pain, infection or other conditions that would require immediate attention.

Limited Oral Evaluation- Problem Focused means an evaluation limited to a specific oral health problem or complaint, as defined by the Current Dental Terminology (CDT) (2014).

Oral Cavity means the jaw, mouth or any structure contiguous to the jaw.

Oral Evaluation For A Patient Under Three Years of Age And Counseling With Primary Caregiver means the diagnostic services performed for a child under the age of three, preferably within the first six months of the eruption of the first primary tooth, including recording the oral and physical health history, evaluation of caries susceptibility, development of an appropriate preventive oral health regimen and communication with and counseling of the child's parent, legal guardian and/or primary caregiver, as defined by the Current Dental Terminology (CDT) (2014).

Palliative Treatment for Dental Pain means emergency treatment to relieve the client of pain; not a mechanism for addressing chronic pain.

Periodic Oral Evaluation means an evaluation performed on a client of record to determine any changes in the patient's dental and medical status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation and periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures, as defined by the Current Dental Terminology (CDT) (2014).

Periodontal Treatment means the therapeutic plan intended to stop or slow periodontal (gum) disease progression.

Preventive services means services concerned with promoting good oral health and function by preventing or reducing the onset or development of oral diseases or deformities and the occurrence of oro-facial injuries, as defined by the Current Dental Terminology (CDT) (2014).

Prophylaxis (Cleaning) is the removal of dental plaque and calculus from teeth in order to prevent dental caries, gingivitis and periodontis.

Qualified Medical Personnel means physicians (MDs), osteopaths (DOs), nurse practitioners and physician assistants with a focus on primary care, general practice, internal medicine, pediatrics and who have participated in on-site training by the "Cavity Free at Three" team or have completed Module 2 (child oral health) and Module 6 (fluoride varnish) in the Smiles for Life curriculum when treating Child Clients age 0 years through 12 years of age. The qualified medical personnel must have participated in Module 3 (adult oral health) and Module 6 (fluoride varnish) in the Smiles for Life curriculum when treating Child Clients ages 12 years and older. Qualified medical personnel who complete this training must provide the documentation of this training when requested.

Re-Evaluation- Limited, Problem Focused (Established Patient; Not Post-Operative Visit) means assessing the status of a previously existing condition. For example, a traumatic injury where no treatment was rendered but patient needs follow-up monitoring; an evaluation for undiagnosed continuing pain; or a soft tissue lesion requiring follow-up evaluation, as defined by the Current Dental Terminology (CDT) (2014).

Restorative means services rendered for the purpose of rehabilitation of dentition to functional or aesthetic requirements of the client, as defined by the Current Dental Terminology (CDT) (2014).

Screening means a program designed to evaluate the health status and potential of an individual. In the process it may be found that a person has a particular disease or condition or is at greater-than-normal risk of its development. Screening may include taking a personal and family health history and performing a physical examination, tests, laboratory tests, or radiologic examination and may be followed by counseling, education, referral, or further testing.

Special Healthcare Needs means any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs. The condition may be developmental or acquired and may cause limitations in performing daily self-maintenance activities or substantial limitations in a major life activity.

Year begins on the date of service.

8.202.2 BENEFITS

8.202.2.A Covered Services
1. Covered Evaluation Procedures:
a. Oral Evaluation For A Patient Under Three Years of Age And Counseling With Primary Caregiver; shall be limited to Child Clients age 0 through 2, two (2) per year per provider or location.
i. Oral Evaluation For A Patient Under Three Years of Age And Counseling With Primary Caregiver shall include:
1. Risk assessment;

2. Oral hygiene instruction; and

3. Anticipatory guidance.

ii. For Child Clients age 0 through 2 who are at high risk for caries, an additional two (2) Oral Evaluation For A Patient Under Three Years of Age And Counseling With Primary Caregiver is allowed per year for a total of four (4) per year; a formal caries risk assessment shall be performed and documented as part of the patient record.

iii. May be performed by dental professional or qualified medical personnel.

iv. Oral Evaluation For A Patient Under Three Years of Age And Counseling With Primary Caregiver will not be reimbursed if it is provided on the same day as a periodic oral evaluation. When both are provided on the same day, only the periodic oral evaluation will be reimbursed.

b. Screening for Child Clients ages 3 and 4, Including State or Federally Mandated Screenings; shall be limited to two (2) per year.
i. For Child Clients ages 3 and 4 who are at high risk for caries, an additional two (2) screenings is allowed per year for a total of four (4) per year; a formal caries risk assessment must be performed and documented as part of the patient record.

ii. Shall be performed by a dental professional or qualified medical personnel.

iii. A screening will not be reimbursed if it is provided on the same day of service as any comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluation. When provided on the same day, only the comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluation will be reimbursed.

c. Screening of a Patient; shall be limited to Child Clients ages 5 years and older, three (3) per year.
i. Shall be performed by dental professional or qualified medical personnel.

ii. Does not count towards other evaluation frequency limits.

iii. A screening will not be reimbursed if it is provided on the same day of service as any comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluation. When provided on the same day, only the comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluation will be reimbursed.

d. Periodic Oral Evaluation, Established Patient; shall be limited to two (2) per year per provider or location.
i. Limited to any combination of two (2) comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluations per year.

ii. Must be rendered by a dental professional.

iii. Periodic oral evaluation will not be reimbursed if it is provided on the same day as an oral evaluation for a patient under three years of age and counseling with primary caregiver. When both are provided on the same day, only the periodic oral evaluation will be reimbursed.

e. Limited Oral Evaluation- Problem Focused; available to Child Clients presenting with a specific oral health condition or problem shall be limited to limited to two (2) per year per provider or location.
i. Must be rendered by a dental professional. Dental hygienists shall only provide limited oral evaluations for a Child Client of record.

ii. Does not count against other oral exam frequencies.

f. Comprehensive Oral Evaluation, New or Established Patient; shall be limited to one (1) every three (3) years per provider or location.
i. Limited to any combination of two (2) comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluations per year.

ii. Must be rendered by a dental professional.

g. Detailed and Extensive Oral Evaluation- Problem Focused, By Report; shall be limited to two (2) per year per provider or location.
i. Limited to any combination of two (2) comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluations per year.

ii. Must be rendered by a dental professional.

h. Re-evaluation- Limited, Problem Focused (Established Patient; Not Post-Operative Visit); shall be limited to two (2) per year per provider or location.
i. Limited to any combination of two (2) comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluations per year.

ii. Must be rendered by a dental professional.

i. Comprehensive Periodontal Oral Evaluation, New or Established Patient; shall be limited to Child Clients ages 15 through 20, one (1) per year per provider or location.
i. Limited to any combination of two (2) comprehensive, periodic, periodontal, oral evaluation for patient under three years of age and counseling with primary caregiver, or limited oral problem focused evaluations per year.

ii. Must be rendered by a dental professional.

2. Covered Diagnostic Imaging Procedures:
a. Intra-oral; complete series, for Child Clients age 6 through 20, shall be limited to one (1) per five (5) years per provider or location; minimum of ten (10) (periapical or posterior bitewing) images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone required in the radiographic survey counts as one (1) set of bitewings per year.

b. Intra-oral first periapical x-ray, shall be limited to six (6) per one (1) year per provider or location. Intra-oral first periapical x-ray will not be reimbursed if it is provided on the same day as a full mouth series. Where both are provided on the same day, only the full mouth series will be reimbursed.

c. Each additional periapical x-ray. Each additional periapical x-ray will not be reimbursed if it is provided on the same day as a full mouth series. Where both are provided on the same day, only the full mouth series will be reimbursed. Working and final treatment films for endodontics are not covered.

d. Bitewing; single image, shall be limited to Child Clients ages 2 through 20, one (1) set per year per provider or location; one set is equal to one (1) to four (4) films.
i. For Child Clients ages 2 through 20 years who are at high risk of caries, bitewing x-rays are a benefit once every six (6) months.

e. Bitewing; two images, shall be limited to Child Clients ages 2 through 20, one (1) set per year per provider or location; one (1) set is equal to two (2) to four (4) films.
i. For Child Clients ages 2 through 20 who are at high risk of caries, bitewing x-rays are a benefit once every six (6) months.

f. Bitewing; three images, shall be limited to Child Clients ages 10 through 20, one (1) set per year per provider or location; one (1) set is equal to two (2) to four (4) films.
i. For Child Clients ages 10 through 20 who are at high risk of caries, bitewing x-rays are a benefit once every six (6) months.

g. Bitewing; four images, shall be limited to Child Clients ages 10 through 20, one (1) set per year per provider or location; one (1) set is equal to two (2) to four (4) films.
i. For Child Clients ages 10 through 20 who are at high risk of caries, bitewing x-rays are a benefit once every six (6) months.

h. Vertical bitewings; shall be limited to Child Clients ages 6 through 20, seven (7) to eight (8) images, one (1) every five (5) years per provider or location. Counts as a full mouth series.

i. Panoramic image; shall be limited to Child Clients ages 6 through 20, with or without bitewing, one (1) per three (3) years per provider or location. Counts as full mouth series.
i. For Child Clients age 6 or under with trauma or suspected pathology, additional panoramic films may be approved subject to EPSDT guidelines.

j. Occlusal film; shall be limited to one (1) per arch per two (2) years per provider or location.
i. For Child Clients with trauma or pulpal treatment, additional occlusal films may be approved subject to EPSDT guidelines.

3. Covered Preventive Services
a. Dental Prophylaxis (Cleaning); shall be limited to two (2) per year. Tooth brushing alone does not qualify as a prophylaxis.

b. Fluoride varnish or fluoride gel, shall be limited to two (2) per year. Fluoride rinse is not a covered benefit.
i. Ages 0 through 4:
1. Child Clients at high risk of caries may receive an additional two (2) per year for a total of four (4) per year; a formal caries risk assessment must be performed and documented as part of the Clients medical record.

2. May be provided by dental professional or qualified medical personnel.
a. Qualified medical personnel administering this service must do so:
i. in conjunction with an oral evaluation for a patient under age 3 (up until day before the third birthday); or

ii. in conjunction with a screening for patients ages 3 through 4 (up until day before the fifth birthday).

3. Fluoride varnish is the only acceptable topical treatment for Child Clients age 0 through 4.

4. Only qualified medical personnel and dental professionals may perform this service.

ii. Age 5 and older:
1. Child Clients age 5 and over may receive an additional one (1) per year with no adjustment for risk for a total of three (3) per year.

2. Fluoride varnish is the only acceptable topical treatment for Child Clients age 5. Fluoride gel will be reimbursed for Child Clients ages 6 and over.

3. Only qualified medical personnel and dental professionals shall perform this service.

4. Covered Space Maintenance.
a. Fixed Space Maintainers for Lost Primary Molars; shall be limited to Child Clients age 0 through 14, two (2) per quadrant per lifetime. Includes maintenance and repair.

b. Removable Space Maintainers for Lost Primary Molars; shall be limited to Child Clients age 0 through 14, two (2) per quadrant per lifetime. Includes maintenances and repair.

c. Re-cementation of Space Maintainer; shall be limited to Child Clients age 0 through 14, one (1) per year. Will not be reimbursed within six (6) months of original placement by the same dentist or group.

d. Removal of a Fixed Space Maintainer; shall be limited to Child Clients age 0 through 20, one (1) per lifetime. Will not be reimbursed to the dentist who placed the appliance or the group where the appliance was originally delivered within six (6) months of original placement. May be subject to post-treatment and prepayment review.

5. Covered Minor Restorative Services.
a. Routine amalgam and composite fillings on posterior and anterior teeth are covered services. Restoration of primary teeth close to exfoliation is not covered.
i. For Child Clients who present with overt symptomatology or ectopic eruption because of an inability to extract the exfoliating teeth themselves, extraction of primary teeth may be approved subject to EPSDT guidelines.

b. The occlusal surface is exempt from the three (3) year frequency limitations listed below when a multi-surface restoration is required or following endodontic therapy.

c. Amalgam and composite fillings shall be limited to one (1) time per surface per tooth, every three (3) years. The limitation shall begin on the date of service and multi-surface fillings are allowable. Amalgam and composite fillings will not be reimbursed if it is provided on the same day of treatment as a crown. Where both are provided on the same day, only the crown will be reimbursed.

d. Prefabricated Stainless Steel Crown, Primary Tooth; may be replaced once every three (3) years.

e. Prefabricated Stainless Steel Crown, Permanent Tooth; may be replaced once every three (3) years.

f. Prefabricated Stainless Steel Crown, with Resin Window; may be replaced once every three (3) years.

g. Protective Restoration, shall be limited to once per lifetime per tooth, primary and permanent teeth.

h. Interim Therapeutic Restoration, Primary Dentition; shall be limited to once per lifetime per tooth, primary teeth only. Not considered a definitive restoration.

6. Covered Major Restorative Services
a. The following crowns are a covered service:
i. Single crowns, shall be limited to one (1) per tooth every seven (7) years. Requires prior authorization.

ii. Core build-up; building, shall be limited to one (1) per tooth every seven (7) years. Requires prior authorization.

iii. Pre-fabricated post and core, shall be limited to one (1) per tooth every seven (7) years. Requires prior authorization.

b. Permanent crowns shall be limited to Child Clients ages 16 years and older.

c. Crowns are covered services only when all of the following conditions are met:
i. The tooth is in occlusion; and

ii. The cause of the problem is either decay or fracture; and

iii. The tooth is not a third molar; and

iv. The Child Client's record reflects evidence of good and consistent oral hygiene; and one of the following is also true:
1. The tooth in question requires a multi-surface restoration and it cannot be restored with other restorative materials; or

2. A crown is requested by the dental professional through the prior authorization process for cracked tooth syndrome and the tooth is symptomatic and appropriate testing and documentation is provided.

d. Crown materials shall be limited to porcelain, full porcelain, noble metal, or high noble metal, on anterior teeth and premolars.

7. Covered Endodontic Services
a. The following endodontic procedures are covered:
i. Therapeutic Pulpotomy (Excluding Final Restoration; removal of the top part of the pulp and application of medicament), shall be limited to one (1) per tooth per lifetime, primary teeth only. Therapeutic Pulpotomy is not allowable as the first state of root canal treatment or for Apexogenesis. Will not be reimbursed if the original treatment was previously reimbursed to the same Provider by Colorado Medicaid.

ii. Pulpal Debridement, shall be limited to one (1) per tooth per lifetime; permanent teeth only.
1. Covered in emergency situations only.

2. Exempt from prior authorization process but may be subject to post-treatment and pre-payment review.

3. Will not be reimbursed when root canal is completed on the same day by the same dentist or dental office.

iii. Partial Pulpotomy for Apexogenesis; shall be limited to one (1) per tooth per lifetime; permanent teeth only.
1. Exempt from prior authorization process but may be subject to post-treatment and pre-payment review.

iv. Root Canal, Anterior Tooth; shall be limited to one (1) per tooth per lifetime; permanent teeth only.

v. Root Canal, Bicuspid; shall be limited to one (1) per tooth per lifetime; permanent teeth only.

vi. Root Canal, Molar; shall be limited to one (1) per tooth per lifetime; permanent teeth only.

vii. Retreatment of Previous Root Canal Therapy, Anterior Tooth; shall be limited to one (1) per lifetime; permanent teeth only. Will not be reimbursed if the original treatment was previously reimbursed to the same dentist or group by Colorado Medicaid. Requires prior authorization.

viii. Retreatment of Previous Root Canal Therapy, Bicuspid Tooth; shall be limited to one (1) per tooth per lifetime. Will not be reimbursed if the original treatment was previously reimbursed to the same dentist or group by Colorado Medicaid. Requires prior authorization.

ix. Retreatment of Previous Root Canal Therapy, Posterior Tooth; shall be limited to one (1) per tooth per lifetime. Will not be reimbursed if the original treatment was previously reimbursed to the same dentist or group by Colorado Medicaid. Requires prior authorization.

x. Apexification/ Recalcification procedures; shall be limited to one (1) per tooth per lifetime; permanent teeth only.
1. Exempt from prior authorization process but may be subject to post-treatment and pre-payment review.

xi. Pulpal Regeneration; shall be limited to one (1) per tooth per lifetime.
1. Exempt from prior authorization process but may be subject to post-treatment and pre-payment review.

b. Endodontic procedures are covered services when:
i. The tooth is not a third molar; and

ii. The Child Client's record reflects evidence of good and consistent oral hygiene; and
1. The cause of the problem is either decay or fracture; and one of the following is also true:
a. The tooth is in occlusion; or

b. A root canal is requested by the dental professional through the prior authorization process for cracked tooth syndrome and the tooth is symptomatic and appropriate testing and documentation is provided.

c. In all instances in which the Child Client is in acute pain or there exists acute trauma, the dentist should take the necessary steps to relieve the pain and complete the Emergency Services. In these instances, there may not be time for prior authorization. Such emergency services shall be subject to post-treatment and pre-payment review.

d. Working films (including the final treatment film) for endodontic procedures are considered part of the procedure and will not be reimbursed separately.

8. Covered Periodontal Treatment
a. Gingivectomy or Gingivoplasty, Four or More Contiguous Teeth or Tooth Bounded Spaces per Quadrant; shall be limited to one (1) per three (3) years per Child Client per quadrant. Includes six (6) months of postoperative care. Requires prior authorization.

b. Gingivectomy or gingivoplasty, One to Three Contiguous Teeth or Tooth Bounded Spaces per Quadrant; shall be limited to one (1) per three (3) years per Child Client per quadrant. Includes six (6) months of postoperative care. Requires prior authorization.

c. Gingivectomy or Gingivoplasty to Allow Access for Restorative Procedure, per Tooth; shall be limited to one (1) per three (3) years per Child Client per quadrant.

d. Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis; shall be limited to Child Clients ages 13 through 20.
i. Exempt from prior authorization process for Child Clients ages 13 through 20 but may be subject to post-treatment and pre-payment review.

ii. Other periodontal treatments will not be reimbursed when provided on the same date as full mouth debridement. Where other periodontal services are provided on the same day, only the full mouth debridement will be reimbursed.

iii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as full mouth debridement. Where both are provided on the same day, only the full mouth debridement will be reimbursed.

e. Periodontal Scaling and Root Planing; Four (4) or More Teeth per Quadrant; shall be limited to once per quadrant every three (3) years.
i. Only covered by report. Periodontal disease must be documented. Requires prior authorization.

ii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as a periodontal scaling and root planing; four (4) or more teeth per quadrant. Where both are provided on the same day, only the periodontal scaling and root planing; four (4) or more teeth per quadrant will be reimbursed.

iii. No more than two (2) quadrants per day.

f. Periodontal Scaling and Root Planing; One (1) to Three (3) Teeth per Quadrant; shall be limited to once per quadrant every three (3) years.
i. Only covered by report. Periodontal disease must be documented in the medical record. Requires prior authorization.

ii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as a periodontal scaling and root planing; one (1) to three (3) teeth per quadrant. Where both are provided on the same day, only the periodontal scaling and root planing; one (1) to three (3) teeth per quadrant will be reimbursed.

iii. No more than two (2) quadrants per day.

g. Periodontal Maintenance; shall be limited to two (2) times per year; counts as a prophylaxis (cleaning).
i. Periodontal maintenance is a covered service for Child Clients age 20 or under who are at high risk of periodontal disease or for caries. Indicators of high risk of periodontal disease include:
1. History of periodontal scaling and root planing; or

2. History of periodontal surgery; or

3. Diabetic diagnosis; or

4. Pregnancy; or

5. By report when periodontal disease can be documented. Requires prior authorization.

h. For child clients who are at high risk for periodontal disease as indicated above, any combination of up to four (4) prophylaxes (cleanings) or four (4) periodontal maintenance visits are allowed per year.

i. In all instances in which the Child Client is in acute pain or there exists acute trauma, the dentist should take the necessary steps to relieve the pain and complete the necessary emergency services. In these instances, there may not be time for prior authorization. Such emergency services shall be subject to post-treatment and pre-payment review.

9. Covered Removable Prosthetics
a. Removable prosthetics are not covered if eight (8) or more posterior teeth (natural or artificial) are in occlusion. Anterior teeth shall be covered, irrespective of the number of teeth in occlusion.

b. Removable prosthetics covered include:
i. Removable Partial Upper Denture, Resin Based; shall be limited to one (1) time every five (5) years. Requires prior authorization.

ii. Removable Partial Lower Denture, Resin Based; shall be limited to one (1) time every five (5) years. Requires prior authorization.

iii. Removable Partial Upper Denture, Cast Metal Framework; shall be limited to one (1) time every five (5) years. Requires prior authorization.

iv. Removable Partial Lower Denture, Cast Metal Framework; shall be limited to one (1) time every five (5) years. Requires prior authorization.

v. Removable Partial Upper Denture, Flexible Base; shall be limited to one (1) time every five (5) years. Requires prior authorization.

vi. Removable Partial Lower Denture, Flexible Base; shall be limited to one (1) time every five (5) years. Requires prior authorization.

vii. Complete Upper Dentures; shall be limited to one (1) time every five (5) years. Includes initial six (6) months of relines. Requires prior authorization.

viii. Complete Lower Dentures; shall be limited to one (1) time every five (5) years. Includes initial six (6) months of relines. Requires prior authorization.

ix. Immediate Upper Dentures; shall be limited to one (1) per lifetime per patient. Includes initial six (6) months of relines. Requires prior authorization.

x. Immediate Lower Dentures; shall be limited to one (1) per lifetime per patient. Includes initial six (6) months of relines. Requires prior authorization.

xi. Obturator Prosthesis, Surgical, Definitive and/or Modification; covered by report. Requires prior authorization.

10. Covered Oral Surgery, Palliative Treatment and Anesthesia
a. The following surgical and palliative treatments are covered:
i. Simple Extraction; shall be limited to one (1) time per tooth.

ii. Surgical Extraction; shall be limited to one (1) time per tooth.

iii. Extraction, Coronal Remnants, Deciduous Tooth; shall be limited to one (1) time per tooth.

iv. Incision and Drainage of Abscess; concurrent with extraction will be covered by report when narrative of medical necessity can be documented. Will not be reimbursed in same surgical area and on same visit as any other definitive treatment codes; except for covered services necessary for diagnosis. Such incision and drainage procedures may be subject to post-treatment and pre-payment review.

v. Palliative Treatment of Dental Pain; will not be reimbursed on same visit as any definitive treatment codes; except for radiographs necessary for diagnosis. Will not be reimbursed when only other service is writing a prescription.

vi. Deep Sedation/General Anesthesia.
1. Only for Child Clients with special health care needs as that term is defined at Section 8.202.1 ., or when there is sufficient evidence to support medical necessity.

2. Nitrous oxide will not be reimbursed if provided on the same day as deep sedation/general anesthesia, intravenous conscious sedation, or non-intravenous conscious sedation. Where multiple levels of anesthesia are provided on the same day, only the deep sedation/general anesthesia will be reimbursed.

vii. Nitrous Oxide; will not be reimbursed if it is provided on the same day as deep sedation/general anesthesia, intravenous conscious sedation, or non-intravenous conscious sedation. Where multiple levels of anesthesia are provided on the same day, only the highest level of anesthesia administered will be reimbursed.

viii. Intravenous Conscious Sedation.
1. Only for Child Clients with special health care needs as that term is defined at Section 8.202.1 ., or when there is sufficient evidence to support medical necessity.

2. Intravenous conscious sedation will not be reimbursed if provided on the same day as deep sedation/general anesthesia, nitrous oxide, or non-intravenous conscious sedation. Where multiple levels of anesthesia are provided on the same day, only the highest level of anesthesia administered will be reimbursed.

ix. Non-Intravenous Conscious Sedation.
1. Only for Child Clients with special health care needs as that term is defined at Section 8.202 .1., or when there is sufficient evidence to support medical necessity.

2. Non- intravenous conscious sedation will not be reimbursed if provided on the same day as deep sedation/general anesthesia, nitrous oxide, or intravenous conscious sedation. Where multiple levels of anesthesia are provided on the same day, only the highest level of anesthesia administered will be reimbursed.

b. In all instances in which the Child Client is in acute pain, the dentist should take the necessary steps to relieve the pain and complete the necessary emergency services. In these instances, there may not be time for prior authorization. Such emergency services shall be subject to post-treatment and pre-payment review.

c. Biopsies are covered only in instances where there is a suspicious lesion.

d. Removal of third molars is only covered in instances of acute pain and overt symptomatology.

e. Extraction of primary teeth which are close to exfoliation will not be covered.
i. For Child Clients who present with overt symptomatology or ectopic eruption because of an inability to extract the exfoliating teeth themselves, extraction of primary teeth may be approved subject to EPSDT guidelines.

11. Covered Hospital-Based Services
a. Dental treatment is covered in a hospital or outpatient facility, under deep sedation or general anesthesia, only when there is medical necessity.

b. Under this Section 11, medical necessity, shall be limited to the following:
i. Patients with a documented physical, mental or medically compromising condition.

ii. Patients who have a dental need and for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy.

iii. Patients who are extremely uncooperative, unmanageable, anxious or uncommunicative and who have dental needs deemed sufficiently urgent that care cannot be deferred. Evidence of the attempt to manage in an outpatient setting must be provided.

iv. Patients who have sustained extensive orofacial and dental trauma.

v. Child Clients ages 6 and under who present with rampant decay.

c. All operating room cases require prior authorization, even if the complete treatment plan is not available.

d. Consistent with the Guidelines of the American Academy of Pediatric Dentistry, the following shall be considered when contemplating treatment of a child under d.eep sedation or general anesthesia:
i. Alternative behavioral guidance modalities.

ii. Dental needs of the patient.

iii. The effect on the quality of dental care.

iv. The patient's emotional development.

v. The patient's medical status.

e. General anesthesia and sedation are not covered services when the patient is cooperative and requires minimal dental treatment, or when the patient has a concomitant medical condition which would make general anesthesia or sedation unsafe.

12. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services will be provided to Child Clients age 20 years and under if the criteria are met.

8.202.2.B. Exclusions.
1. Notwithstanding exceptions for EPSDT Services, the following services/treatments are not a benefit for Child Clients age 20 years and under:
a. Cosmetic Procedures.

b. Crowns in the following categories:
i. Cosmetic crowns;

ii. Multiple units of crown and bridge;

iii. To restore vertical dimension;

iv. When Child Client has active and advanced periodontal disease;

v. When the tooth is not in occlusion; or vi. When there is evidence of periapical pathology.

c. Implants.

d. Endodontic surgery.

e. Treatment for temporomandibular joint disorders.

f. Oral hygiene instruction.

g. Working and final treatment films for root canal treatment.

h. Root canals for third molars.

i. Removal of third molars. Removal of third molars is only covered in instances of acute pain and overt symptomatology.

j. Any service that is not listed as covered.

8.202.3 PRIOR AUTHORIZATION REQUEST

1. Emergency Services do not require a prior authorization and shall be subject to prepayment review.

2. Prior authorizations or benefits shall be denied for reasons of poor dental prognosis, lack of dental necessity or appropriateness or because the requested services do not meet the generally accepted standard of dental care.

3. The following services require prior authorization:
a. Single crowns; core build-ups; post and cores.

b. Gingivectomy.

c. Complete, partial, and immediate dentures.

d. Obturators.

e. Scaling and root planing (periodontal maintenance).

f. Retreatment of root canals; prior authorization is not required for pulpal debridement in instances of acute pain.

g. Hospital-based services when treatment is required.

8.202.4. PROVIDER REQUIREMENTS/REIMBURSEMENT

8.202.4.A. Dental services shall only be provided by a dental professional who is enrolled with Colorado Medicaid with the exception of services rendered to Child Clients by qualified medical personnel. Providers shall only provide covered services that are within the scope of their practice.

8.202.4.B. The following billing limitations apply:
1. Restorations:
a. Tooth preparation, anesthesia, all adhesives, liners and bases, polishing and occlusal adjustments are included within the reimbursement rate for restoration. Unbundling of dental restorations for billing purposes is not allowed.

b. Restorations for permanent and primary teeth are paid at the same rate.

c. The total restorative fee for a primary tooth cannot exceed the current maximum benefit for a prefabricated stainless steel crown.

d. Amalgam and composite restorations are reimbursed at the same rate.

e. Claim payment to a dental provider for one (1) or more restorations for the same tooth is limited to a total of four (4) tooth surfaces.

2. Pulpal debridement; if a dentist completes a pulpal debridement procedure, and subsequently completes a root canal on the same tooth; payment for the pulpal debridement will be subtracted from the final root canal payment.

3. Hospital procedures; payment for services performed in the operating room or outpatient facility, when scheduled for the convenience of the provider or the patient in the absence of medical necessity, will not be reimbursed.

4. In the event that two or more treatments could be used to adequately diagnose and treat a dental condition, the Provider shall use the least costly of those options in accordance with best dental practices.

5. If a procedure is not listed as covered benefit, the procedure will not be covered, unless special consideration and approval has been obtained, to reflect extenuating circumstances.

6. A client may make personal expenditures for services not covered by Medicaid and shall be charged the lower of the Medicaid Fee Schedule or submitted charges.

8.202.5 ELIGIBLE CLIENTS

Dental services described in this Section 8.202 shall apply to Child Clients age 20 years and under.

Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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