Current through Register 1531, September 27, 2024
The MassHealth agency pays for restorative services in
accordance with the service descriptions and limitations in 130 CMR 420.425(A)
through (E). The MassHealth agency considers all of the following to be
components of a completed restoration (local anesthesia tooth preparation, acid
etching, all adhesives applications, resin bonding agents, amalgam bonding
agents, liners, bases, amalgams, resin-based composites, glass ionomers, curing
and polishing) and includes them in the payment for this service. The
MassHealth agency does not pay for composite or amalgam restorations replaced
within one year of the date of completion of the original restoration when
replaced by the same provider or dental group. The initial payment includes all
restorations replaced due to defects or failure less than one year from the
original placement.
(A)
Amalgam Restorations. The MassHealth agency does not
pay for restorations on primary teeth when early exfoliation (more than
2/3 of the root
structure resorbed) is expected.
(B)
Resin-based Composite
Restorations.
(1) The MassHealth
agency pays for:
(a) all resin-based
composite restorations for all surfaces of anterior and posterior teeth;
and
(b) full-coverage composite
crowns only for members younger than 21 years old, only for anterior primary
teeth.
(2) For anterior
teeth, the MassHealth agency pays no more than the maximum allowable payment
for four-or-more-surface resin-based composite restorations on the same tooth,
except for reinforcing pins.
(3)
The MassHealth agency pays for only one resin-based composite restoration per
member per tooth surface per 12 months per provider or provider
location.
(4) The MassHealth agency
does not pay more for a composite restoration on a posterior (primary or
permanent) tooth than it would for an amalgam restoration.
(C)
Crowns, Posts and
Cores.
(1)
Members
Younger than 21 Years Old. The MassHealth agency pays for the
following crown materials on permanent incisors, cuspids, bicuspids, and first
and second molars:
(a) crowns made from
resin-based composite (indirect);
(b) crowns porcelain-fused to predominantly
base metal;
(c) crowns
porcelain-fused to high noble metal;
(d) crowns made from porcelain or
ceramic;
(e) crowns porcelain-fused
to semi-precious metal;
(f) full
case high noble metal;
(g) posts
and cores and/or pin retention; and
(h) prefabricated porcelain/ceramic crown -
primary tooth; and
(i)
prefabricated stainless steel crowns for primary and permanent posterior teeth
or prefabricated resin crowns for primary and permanent anterior teeth.
Stainless steel or prefabricated resin crowns are limited to instances where
the prognosis is favorable and must not be placed on primary teeth that are
mobile or show advanced resorption of roots. The MassHealth agency pays for no
more than four stainless steel or prefabricated resin crowns per member per
date of service, except in cases that are treated in a hospital operating room
or ambulatory care center.
(2)
Members 21 Years of Age and
Older. The MassHealth agency pays for the following crown
materials on permanent incisors, cuspids, bicuspids, and first and second
molars:
(a) crowns porcelain fused to
predominantly base metal;
(b)
crowns made from porcelain or ceramic;
(c) stainless steel crowns only if crown
porcelain fused to predominately base metal is unsuitable and extraction (the
alternative treatment) would cause undue medical risk for a member with one or
more medical conditions that include, but are not limited to,
1. hemophilia;
2. history of radiation therapy;
3. acquired or congenital immune
disorder;
4. severe physical
disabilities such as quadriplegia;
5. profound intellectual or developmental
disabilities; or
6. profound mental
illness; and
(d) posts
and cores and/or pin retention.
(D)
Reinforcing Pins
. The MassHealth agency pays for reinforcing pins only when used in conjunction
with a two-or-more-surface restoration on a permanent tooth. Commercial amalgam
bonding systems are included in this category.
(E)
Crown or Bridge
Repair. The MassHealth agency pays for chairside crown repair for
all members and fixed partial denture repair only for members younger than 21
years old. A description of the repair must be documented in the member's
dental record. The MassHealth agency pays for unspecified restoration
procedures for crown repair by an outside laboratory only if the repair is
extensive and cannot be done chairside.
