Current through Register 1531, September 27, 2024
(A)
Medically Necessary
Services. The MassHealth agency pays for the following
Dental Services when medically necessary:
(1) the services with codes listed in
Subchapter 6 of the Dental Manual, in accordance with the
service descriptions and limitations described in
130 CMR
420.422 through
420.456;
and
(2) all services for
EPSDT-eligible members, in accordance with
130
CMR 450.140 through
450.149,
without regard for the service limitations described in
130 CMR
420.422 through
420.456,
or the listing of a code in Subchapter 6. All such services are available to
EPSDT-eligible members, with prior authorization, even if the limitation
specifically applies to other members younger than 21 years
old.
(B)
Non-covered Services. The MassHealth agency does not
pay for the following services for any member, except when MassHealth
determines the service to be medically necessary and the member is younger than
21 years old. Prior authorization must be submitted for any medically necessary
non-covered services for members younger than 21 years old.
(1) cosmetic services;
(2) certain dentures including unilateral
partials, overdentures and their attachments, temporary dentures, CuSil-type
dentures, other dentures of specialized designs or techniques, and preformed
dentures with mounted teeth (teeth that have been set in acrylic before the
initial impressions);
(3)
counseling or member education services;
(4) habit-breaking appliances;
(5) implants of any type or
description;
(6) laminate
veneers;
(7) oral hygiene devices
and appliances, dentifrices, and mouth rinses;
(8) orthotic splints, including mandibular
orthopedic repositioning appliances;
(9) panoramic films for crowns, endodontics,
periodontics, and interproximal caries;
(10) root canals filled by silver point
technique, or paste only;
(11)
tooth splinting for periodontal purposes; and
(12) any other service not listed in
Subchapter 6 of the Dental Manual.
(C)
Covered Services for All
Members 21 Years of Age or Older. The MassHealth agency pays for
the services listed in
130 CMR
420.422 through
420.456
for all members 21 years of age or older in accordance with the service
descriptions and limitations set forth therein:
(1) diagnostic services as described in
130 CMR
420.422;
(2) radiographs as described in
130 CMR
420.423;
(3) preventive services as described in
130 CMR
420.424;
(4) restorative services as described in
130 CMR
420.425;
(5) endodontic services as described in
130 CMR
420.426;
(6) periodontal services as described in
130 CMR
420.427;
(7) prosthodontic services as described in
130
CMR 420.428;
(8) oral surgery services as described in
130
CMR 420.430;
(9) anesthesia services as described in
130 CMR
420.452;
(10) oral and maxillofacial surgery services
as described in
130
CMR 420.453;
(11) maxillofacial prosthetics as described
in
130
CMR 420.455;
(12) behavior management services as
described in
130 CMR
420.456(B);
(13) palliative treatment of dental pain or
infection services as described in
130 CMR
420.456(C); and
(14) house/facility call as described in
130 CMR
420.456(F).
(D)
Non-covered Services for
Members 21 Years of Age or Older. The MassHealth agency does not
pay for the following services for members 21 years of age or older:
(1) preventive services as described in
130 CMR
420.424(C);
(2) prosthodontic services (fixed) as
described in
130
CMR 420.429; and
(3) other services as described in
130 CMR
420.456(A), (B), (E), and
(F).
