Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 6 - DENTAL SERVICES
Section 471-6-004 - SERVICE REQUIREMENTS

Universal Citation: 471 NE Admin Rules and Regs ch 6 ยง 004

Current through September 17, 2024

004.01 GENERAL REQUIREMENTS.

004.01(A) MEDICAL NECESSITY. Medicaid incorporates the definition of medical necessity from 471 NAC 1 as if fully rewritten herein. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered. Services may be subject to the specific limitations or prior authorization requirements as listed in this chapter.
004.01(A)(i) DOCUMENTATION OF MEDICAL NECESSITY. Documentation of medical necessity is required on all procedures. The documentation should be in the client's dental chart which must be available to the Department upon request.

004.01(B) PRIOR AUTHORIZATION. Specific documentation must be submitted along with each prior authorization request. Submitted documentation that is inadequate, or does not otherwise meet the criteria for review, may be disapproved, or returned for additional information or correction. The provider must receive prior authorization before the following services:
(i) Crowns;

(ii) Periodontal scaling and root planning;

(iii) Periodontal maintenance procedure;

(iv) Complete, immediate, and interim dentures, maxillary and mandibular;

(v) Partial resin base, maxillary and mandibular;

(vi) Flipper partial dentures, maxillary and mandibular; and

(vii) Orthodontic treatment.

004.01(B)(i) REQUEST FOR PRIOR AUTHORIZATION. To request prior authorization for a proposed dental pre-treatment plan or covered service, the dentist must submit the request using one of the following options:
(1) Electronically using the standard Health Care Services Request for Review and Response; or

(2) Submission of a dental claim form and required documentation by mail to the Department.

004.01(B)(ii) ADULT EMERGENCY DENTAL SERVICES AND EXTENSIVE TREATMENT CIRCUMSTANCES. The request must clearly indicate that it is either an emergency services or extensive treatment circumstances request, and be accompanied by sufficient documentation to determine the emergent medical necessity. In the event that the service must be rendered immediately, the dental provider must submit a request for coverage, post treatment, with documentation of the emergent medical necessity, for payment review.

004.01(C) SERVICES FOR INDIVIDUALS AGE 21 AND OLDER. Dental coverage is limited to $750 per fiscal year. The annual limit is calculated at the Medicaid dental fee schedule rate for the treatment provided or on the all-inclusive encounter rate paid to Indian health service (IHS) facilities or federally qualified health centers (FQHC) facilities.
004.01(C)(i) PROVIDER RESPONSIBILITY AND CLIENT RESPONSIBILITY REGARDING THE YEARLY DENTAL LIMIT. Providers must inform a client before treatment is provided of the client's obligation to pay for a service if the client's annual limit has already been reached or if the amount of treatment proposed will cause the client's annual limit to be exceeded.

004.01(C)(ii) EMERGENCY DENTAL SERVICES. Adult dental services provided in an emergency situation are not subject to the annual per fiscal year limits imposed in this chapter. Adult dental services provided in an emergency situation will be considered for coverage on a case-by-case basis. Only the most limited service(s) needed to correct the emergency condition will be covered. Medicaid will cover emergency dental services that were not prior authorized. The provider must submit a completed coverage request with supporting documentation of the emergent nature of the services provided. Medicaid considers the following conditions to be emergent:
(1) Extractions for the relief of:
(a) Severe and acute pain; or

(b) An acute infectious process in the mouth;

(2) Extractions and necessary treatment for repair of traumatic injury; and

(3) Full mouth extractions as necessary for catastrophic illness such as an organ transplant, chemotherapy, severe heart disease, intraoral radiation workup, or other life threatening illnesses.

004.01(C)(iii) DENTURES AND EXTENSIVE TREATMENT CIRCUMSTANCES. Medicaid will review, and consider coverage of, services that cause the client to exceed the annual coverage limit, where the client is in need of dentures and extensive treatment in a hospital setting due to a disease or medical condition, or the client is disabled and it is in the best interest of the client's overall health to complete the treatment in a single setting. A prior authorization request must be submitted with medical necessity documentation.

004.01(D) SERVICES PROVIDED TO CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

004.01(E) HEALTH CHECK SERVICES. See 471 NAC 33.

004.01(F) HOSPITALIZATION OR TREATMENT IN AN AMBULATORY SURGICAL CENTER. Dental services must be provided at the least expensive appropriate place of service.

004.01(G) MEDICAL AND SURGICAL SERVICES OF A DENTIST OR ORGAL SURGEON. Medically necessary services of a dentist or oral surgeon not otherwise covered in this chapter, are covered and reimbursed as a physician's service in accordance with the 471 NAC 18.

004.02 COVERED SERVICES. Medicaid does not cover all American Dental Association (ADA) procedure codes. Covered codes are listed in the Medicaid Dental Fee Schedule.

004.02(A) DIAGNOSTIC SERVICES.
004.02(A)(i) ORAL EVALUATIONS. Oral evaluations are covered for new patients, emergency treatment, second opinions and specialists. All oral examinations must be provided by a dentist. A single exam code is covered per date of service. Not to be billed with any other exam codes on the same date of service.
004.02(A)(i)(1) PERIODIC ORAL EVALUATIONS.
004.02(A)(i)(1)(a) AGE 20 AND YOUNGER. For clients age 20 and younger, periodic oral evaluation is covered once every 180 days.

004.02(A)(i)(1)(b) AGE 21 AND OLDER. For clients age 21 and older, periodic oral evaluation is covered once every 180 days.

004.02(A)(i)(1)(c) SPECIAL NEEDS AND DISABLED CLIENTS. Periodic oral evaluation is covered at the frequency determined appropriate by the treating dental provider.

004.02(A)(i)(1)(d) DOCUMENTATION REQUIREMENTS. Documentation of client's special needs or disability is required.

004.02(A)(i)(2) LIMITED ORAL EVALUATION. Oral evaluation is limited to twice in a one year period for each client, and for treatment of a specific oral health problem or complaint. Documentation which specifies the medical necessity is required.

004.02(A)(i)(3) ORAL EVALUATION FOR INFANT. Oral evaluation is covered for clients age 3 and younger and includes counseling with the primary caregiver.

004.02(A)(i)(4) COMPREHENSIVE ORAL EVALUATION. Benefit is limited to one per three year period per client, per provider, and location. It is not payable in conjunction with emergency treatment visits, denture repairs, or similar appointments.

004.02(A)(i)(5) DETAILED AND EXTENSIVE ORAL EXAMINATION. Problem focused oral evaluation is a benefit limited to one per three year period per client. It is not payable in conjunction with emergency treatment visits, denture repairs or similar appointments.

004.02(A)(i)(6) RE-EVALUATION. Limited and problem focused benefit is limited to one per year per client.

004.02(A)(i)(7) COMPREHENSIVE PERIODONTAL EVALUATION. Comprehensive periodontal evaluation is a benefit limited to one per three year period per client.

004.02(A)(ii) RADIOGRAPHS. The maximum dollar amount covered is equal to the Medicaid fee paid for an intraoral complete series. A cephalometric film is not included in the maximum dollar amount. Medicaid covers a maximum dollar amount for any combination of the following radiographs:
(1) Intraoral complete series;

(2) Intraoral periapical films;

(3) Extraoral films, bitewings; or

(4) Panorex.

004.02(A)(iii) PERIODOCITY OF RADIOGRAPHS. Medicaid covers:
(1) A maximum of four bitewings per date of services;

(2) Intraoral complete series every three years;

(3) Panorex every three years. Covered more frequently if necessary for treatment. Documentation is required for more frequent panorex in dental chart; and

(4) Cephalometric film for clients age 20 and younger, as follows:
(a) Orthodontic treatment is covered if the client will qualify for Medicaid coverage of treatment as outlined in the orthodontic coverage criteria.

004.02(B) PREVENTIVE SERVICES.
004.02(B)(i) PROPHYLAXIS.
004.02(B)(i)(1) AGE 13 AND YOUNGER. For age 13 and younger, prophylaxis is covered one time every 180 days and billed as a child prophylaxis.

004.02(B)(i)(2) AGE 14 THROUGH 20. For age 14 through 20, prophylaxis is covered every 180 days and billed as an adult prophylaxis.

004.02(B)(i)(3) AGE 21 AND OLDER. For age 21 and older, prophylaxis is covered one time every 180 days.

004.02(B)(i)(4) SPECIAL NEEDS CLIENTS. Prophylaxis is covered at the frequency determined appropriate by the treating dental provider and is limited to one per date of service per client.
004.02(B)(i)(4)(a) DOCUMENTATION REQUIREMENTS. Documentation of client's special needs or disability is required.

004.02(B)(ii) TOPICAL FLUORIDE AND FLUORIDE VARNISH. Topical fluoride and fluoride varnish are covered for adults and children at the frequency determined appropriate by the treating dental provider.

004.02(B)(iii) SEALANTS. Sealants are covered on permanent and primary teeth for clients ages 20 and younger. Sealants are covered once per tooth every 730 days.

004.02(B)(iv) SPACE MAINTAINERS, PASSIVE APPLIANCES. Space maintainers are covered for clients age 20 and younger, once every 365 days.

004.02(B)(v) RECEMENTATION OF SPACE MAINTAINERS. Recementation is covered for clients age 20 and younger, once every 365 days.

004.02(C) RESTORATIVE SERVICES. Tooth preparation, temporary restorations, cement bases, pulp capping, impressions, and local anesthesia are included in the restorative fee for each covered service.
004.02(C)(i) AMALGAM OR RESIN. Resin refers to a broad category of materials including but not limited to composites, and glass ionomers. Full labial veneers for cosmetic purposes are not covered.
004.02(C)(i)(1) DOCUMENTATION REQUIREMENTS. Documentation of carious lesions must be present.

004.02(C)(i)(2) MAXIMUM FEE. A maximum fee is covered per tooth for any combination of amalgam or resin restoration procedure codes. The maximum fee is equal to the Medicaid fee for a four or more surface restoration.

004.02(C)(ii) CROWNS. Crowns are covered for anterior and bicuspid teeth when other restoration is not possible. Crowns are covered for molar teeth that have been endodontically treated, and cannot be adequately restored with a stainless steel crown, amalgam, or resin restoration. Crowns are not covered for third molars. A replacement crown for the same tooth in less than 1,825 days, due to failure of the crown, is not covered and is the responsibility of the dentist who originally placed the crown.
004.02(C)(ii)(1) DOCUMENTATION REQUIREMENTS. Submit x-ray of anterior and bicuspids, or x-ray of molar that shows completed root canal. A request should not be submitted for unusual or exceptional situations not covered herein.

004.02(C)(iii) PREFABRICATED STAINLESS STEEL CROWNS. Prefabricated stainless steel crowns are covered for primary and permanent teeth.

004.02(C)(iv) PREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOW. Prefabricated stainless steel crown with resin window is covered for primary anterior teeth.

004.02(C)(v) SEDATIVE FILLING. Sedative filling is covered once per tooth every 365 days.

004.02(C)(vi) UNSPECIFIED RESTORATIVE PROCEDURE, BY REPORT. This code is used for procedures that are not adequately described by another code. This code must not be used to claim an item that has an American Dental Association (ADA) code, but is not covered by Medicaid.
004.02(C)(vi)(1) DOCUMENTATION REQUIREMENTS. A description of treatment provided must be submitted with the claim. This service is reviewed prior to payment.

004.02(D) ENDODONTICS.
004.02(D)(i) THERAPEUTIC PULPOTOMY AND PUPAL THERAPY. Medicaid covers therapeutic pulpotomy and pupa therapy for primary teeth only, and is not covered for permanent teeth.

004.02(D)(ii) ROOT CANAL THERAPY AND RE-TREATMENT OF PREVIOUS ROOT CANALS. Root canal therapy and re-treatment are covered for permanent teeth. Root canal treatment includes a treatment plan, necessary appointments, clinical procedures, radiographic images and follow up care. Re-treatment of previous root canals may be covered if at least 365 days have passed since the original treatment, and failure has been demonstrated with x-ray documentation and narrative summary.
004.02(D)(ii)(1) LIMITATIONS. Root canal therapy and re-treatment of previous root canals are not covered for third molars.

004.02(D)(ii)(2) DOCUMENTATION REQUIREMENTS. Post-op x-ray of completed root canal must be available for review by Department upon request.

004.02(D)(iii) APICOECTOMY. Apicoectomy is covered on permanent anterior teeth.

004.02(D)(iv) EMERGENCY TREATMENT TO RELIEVE ENDODONTIC PAIN. Emergency treatment to relieve endodontic pain is covered as unspecified endodontic procedure, by report code. Tooth number must be identified on the claim submission. This is not to be submitted with any other definitive treatment codes on same tooth on same day of service.

004.02(E) PERIODONTICS.
004.02(E)(i) GINGIVECTOMY OR GINGIVOPLASTY. Medicaid covers gingivectomy or gingivoplasty per tooth or per quadrant.

004.02(E)(ii) PERIODONTAL SCALING AND ROOT PLANING. Medicaid covers four quadrants of scaling and root planing once every 365 days. Each quadrant is covered one time per client. The request for approval must be accompanied by the following:
(a) A periodontal treatment plan;

(b) A completed copy of a periodontic probe chart that exhibits pocket depths;

(c) A periodontal history, including home oral care; and

(d) Radiography.

004.02(E)(ii)(1) EXCLUSIONS. For scaling and root planing that requires the use of local anesthesia, Medicaid does not cover more than one half of the mouth in one day, except on hospital cases.

004.02(E)(ii)(2) DOCUMENTATION REQUIREMENTS. A treatment plan that demonstrates that curettage, scaling, or root planning is required in addition to a routine prophylaxis. Providers must submit the following documentation with prior authorization request:
(a) Periapical x-rays demonstrating subgingival calculus and loss of crestal bone; and

(b) Periodontal probe chart evidencing active periodontal disease and pocket depths of 4 millimeters (mm) or greater.

004.02(E)(iii) FULL MOUTH DEBRIDEMENT. Medicaid covers one full mouth debridement procedure every 365 days per client. Not covered on the same date of service as prophylaxis.

004.02(E)(iv) PERIODONTAL MAINTENANCE PROCEDURE. Medicaid covers periodontal maintenance procedure for clients that have had Medicaid approved periodontal scaling and root planing. Prior authorization must be renewed annually.
004.02(E)(iv)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:
(a) Date the Medicaid approved scaling and root planing completed;

(b) Periodontal history; and

(c) Frequency the dental provider is requesting that the client must be seen for maintenance procedure.

004.02(F) PROSTHODONTICS. Coverage of prosthetic appliances includes all materials, fitting, and placement of the prosthesis, and all necessary adjustments for a period of 180 days following placement of the prosthesis. Medicaid covers the following prosthetic appliances, subject to service specific coverage criteria:
(1) Dentures that are immediate, replacement or complete, or interim or complete;

(2) Resin base partial dentures, including metal clasps;

(3) Flipper partials that are considered a permanent replacement of one to three anterior teeth only; and

(4) Cast metal framework with resin denture base partials, covered for clients age 20 and younger.

004.02(F)(i) REPLACEMENT. Medicaid covers a one-time replacement within the five year coverage limit for broken, lost, or stolen appliances. This one-time replacement is available once within each client's lifetime, and a prior authorization request must be submitted and marked as a one-time replacement request. Replacement of any prosthetic appliance is covered once every five years when:
(1) The client's dental history does not show that previous prosthetic appliances have been unsatisfactory to the client;

(2) The client does not have a history of lost prosthetic appliances;

(3) A repair will not make the existing denture or partial functional;

(4) A reline will not make the existing denture or partial functional; or

(5) A rebase will not make the existing denture or partial functional.

004.02(F)(ii) COMPLETE DENTURES, MAXILLARY AND MANDIBULAR. Complete dentures, maxillary and mandibular, are covered 180 days after placement of interim dentures. Relines, rebases, and adjustments are not billable for 180 days after placement of the prosthesis.
004.02(F)(ii)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:
(a) Date of previous denture placement;

(b) Information on condition of existing denture; and

(c) For initial placements, submit panorex or full mouth series radiographs.

004.02(F)(iii) IMMEDIATE DENTURE, MAXILLARY AND MANDIBULAR. An immediate denture, maxillary and mandibular, is considered a permanent denture. Relines or rebases are not billable for 180 days after placement of the prosthesis.
004.02(F)(iii)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:
(a) Date and list of teeth to be extracted;

(b) Narrative documenting medical necessity; and

(c) Submit panorex or full mouth series radiographs.

004.02(F)(iv) PARTIAL RESIN BASE, MAXILLARY OR MANDIBULAR. Partial resin base, maxillary or mandibular, is covered if the client does not have adequate occlusion. Cast metal clasps are included on partial dentures. One to three missing anterior teeth should be replaced with a flipper partial which is considered a permanent replacement.
004.02(F)(iv)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:
(a) Chart or list of missing teeth and teeth to be extracted;

(b) Age and condition of any existing partial, or a statement identifying the prosthesis as an initial placement;

(c) Narrative documenting how there is not adequate occlusion; and

(d) For initial placements, radiographs of remaining teeth are required.

004.02(F)(v) PARTIAL CAST METAL BASE, MAXILLARY OR MANDIBULAR. Partial cast metal base, maxillary or mandibular is covered for clients age 20 and younger only. More than one posterior tooth must be missing for partial placement. One to three missing anterior teeth should be replaced with a flipper partial which is considered a permanent replacement.

004.02(F)(vi) ADJUSTMENTS TO DENTURES AND PARTIALS. Adjustments to dentures and partials are not covered for 180 days following placement of a new prosthesis. Adjustments after 180 days are billable as needed to make prosthesis wearable.

004.02(F)(vii) REPAIRS TO DENTURES AND PARTIALS. Medicaid covers two repairs per prosthesis every 365 days.

004.02(F)(viii) REBASE OF DENTURES AND PARTIALS. Rebase of dentures and partials are covered following the placement of a new prosthesis after 180 days have passed and, covered once per prosthesis every 365 days. Chair side and lab rebases are covered, but only one can be provided within the 365 day period.

004.02(F)(ix) RELINE OF DENTURES AND PARTIALS. Reline of dentures and partials are covered following the placement of a new prosthesis after 180 days have passed. Covered once per prostheses every 365 days. Chair side and lab relines are covered, but only one can be provided within the 365 day period.

004.02(F)(x) INTERIM COMPLETE DENTURES, MAXILLARY AND MANDIBULAR. Interim dentures can be replaced with a complete denture 180 days after placement of the interim denture. Complete dentures require prior authorization in accordance with this chapter.
004.02(F)(x)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:
(a) Date and list of teeth to be extracted;

(b) Narrative documenting medical necessity; and

(c) Submit panorex or full mouth series radiographs.

004.02(F)(xi) FLIPPER PARTIAL DENTURES, MAXILLARY AND MANDIBULAR. Flipper partial dentures, maxillary and mandibular are considered a permanent replacement for one to three anterior teeth. It is not covered for temporary replacement of missing teeth. Relines, rebases, and adjustments are not billable for 180 days after placement of the prosthesis.
004.02(F)(xi)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:
(a) Chart or list missing teeth and teeth to be extracted;

(b) Age and condition of existing partials, or a statement identifying the prosthesis as an initial placement; and

(c) Radiographs.

004.02(F)(xii) TISSUE CONDITIONING. Covered one time during the first 180 days following placement of a prosthetic appliance. Following the initial 180 days, necessary tissue conditioning may be covered two times per prosthesis every 365 days, with documentation in the dental record.

004.02(G) ORAL AND MAXILLOFACIAL SURGERY.
004.02(G)(i) EXTRACTIONS ROUTINE AND SURGICAL. Medicaid covers necessary extraction of teeth when there is documented medical need for the extraction. The Medicaid fee for extractions includes local anesthesia, suturing if needed, and routine postoperative care.
004.02(G)(i)(1) DOCUMENTATION REQUIREMENTS. Providers must document the medical reason for extractions in the dental chart.

004.02(G)(ii) TOOTH REIMPLANTATION AND STABILIZATION OF AN ACCIDENTALLY AVULSED OR DISPLACED TOOTH OR ALVEOLUS. The Medicaid fee includes splinting and stabilization.

004.02(G)(iii) SURGICAL EXPOSURE OF IMPACTED OR UNERUPTED TOOTH FOR ORTHODONTIC REASONS. The Medicaid fee includes the orthodontic attachment.

004.02(G)(iv) BIOPSY OF ORAL TISSUE, HARD OR SOFT. The Medicaid fee is for the professional component only. The lab must bill the specimen charge.

004.02(G)(v) ALVEOLOPLASTY. The Medicaid fee for extractions includes routine recontouring of the ridge and suturing as necessary. It is not a separate billable procedure.
004.02(G)(v)(1) ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS. The Medicaid fee covers alveoloplasty in conjunction with extractions, per quadrant as a separate procedure, when it is necessary beyond routine recontouring to prepare the ridge for a prosthetic appliance.

004.02(G)(vi) EXCISIONS. Excision is the surgical removal, act of cutting out, a part or all gingival and or alveolar structure within the oral cavity. The Medicaid fee is for the excision. The lab must bill the specimen charge.

004.02(G)(vii) OCCLUSAL ORTHOTIC DEVICE, BY REPORT. The fee includes any necessary adjustments. For treatment of bruxism or for minor occlusal problems, see occlusal guard in this chapter.
004.02(G)(vii)(1) DOCUMENTATION REQUIREMENTS. Providers must document the type of appliance made, and medical necessity.

004.02(H) ORTHODONTICS. Medicaid covers prior authorized orthodontic treatment for clients who are age 20 or younger, and have a handicapping malocclusion.
004.02(H)(i) COVERAGE CRITERIA FOR DIAGNOSTIC MODELS AND RADIOGRAPHS. Diagnostic records are not covered by Medicaid unless the case will qualify for Medicaid coverage as outlined in this chapter. Diagnostic records for minor malocclusions are not covered by Medicaid. For auditing purposes, Medicaid may request end of treatment diagnostic models and x-rays. Payment for the end of treatment records will be included in the dollar amount prior authorized. The end of treatment records must be submitted to the Department for review.

004.02(H)(ii) FORMS. Medicaid uses the Nebraska Index of Orthodontic Treatment Need (NIOTN) form to determine whether coverage is appropriate based on a handicapping malocclusion. A score of 28 or greater being necessary to qualify for Medicaid coverage of orthodontic treatment. The Nebraska Index of Orthodontic Treatment Need (NIOTN) form must be used to pre-screen orthodontic cases.

004.02(H)(iii) ORTHODONTIC TREATMENT. To be eligible for orthodontic treatment, a client must be age 20 or younger when treatment is authorized, and have a handicapping malocclusion, which includes one or more of the following five documented conditions:
(a) Accident causing a severe malocclusion;

(b) Injury causing a severe malocclusion;

(c) Condition that was present at birth causing a severe malocclusion;

(d) Medical condition causing a severe malocclusion; and

(e) Facial skeletal condition causing a severe malocclusion.

004.02(H)(iii)(1) SURGICAL CORRECTION. When the individual has had a surgical correction of a cleft lip or palate, or orthognathic correction, the monthly adjustment procedure is reimbursed at a higher fee. The pre-treatment request must contain documentation of the client's medical condition, or surgical correction.

004.02(H)(iii)(2) AUTHORIZATION. Treatment is prior authorized and paid on a single procedure code. The authorized code will be on the Form MC-9D, Dental Authorization and Treatment. In order for Medicaid clients to receive timely treatment, the request for approval will constitute the providers acceptance of the Medicaid fee, and a commitment to complete care.

004.02(H)(iii)(3) DOCUMENTATION REQUIREMENTS. The following documentation must be submitted with the prior authorization request:
(a) A pre-treatment request form that outlines treatment and the Nebraska Index of Orthodontic Treatment Need (NIOTN) form;

(b) Diagnostic records including:
(i) Diagnostic casts and oral or facial photographic images;

(ii) Full mouth radiographs and panoramic x-ray; and

(iii) Cephalometric x-ray;

(c) A narrative description of the diagnosis, and prognosis; and

(d) On surgical cases, include a description of the procedure to be completed.

Following completed surgery, a surgical letter of documentation is required accompanying an additional prior authorization request for the added surgical fee.

004.02(H)(iv) INTERCEPTIVE ORTHODONTIC TREATMENT OF TRANSITIONAL DENTITION. The interceptive orthodontic treatment of transitional dentition is covered if it is the cost effective method to lessen the severity of a malformation such that extensive treatment is not required.

004.02(H)(v) REMOVABLE AND FIXED APPLIANCE FOR THUMB SUCKING AND TONGUE THRUST. Removable and fixed appliance for thumb sucking and tongue thrust is covered for clients age 20 and younger, and includes adjustments.

004.02(H)(vi) REPAIR OF ORTHODONTIC APPLIANCES. Repair is covered for clients age 20 and younger.
004.02(H)(vi)(1) DOCUMENTATION REQUIREMENTS. Documentation must include a description of the repair on the dental claim, and in the dental chart.

004.02(H)(vii) ORTHODONTIC RETAINERS, REPLACEMENT. Retainers are covered for clients age 20 and younger if the client is compliant with wearing the appliance.

004.02(H)(viii) REPAIR OF BRACKET AND STANDARD FIXED ORTHODONTIC APPLIANCES. Repair is covered for clients age 20 and younger, when repairs exceed routine repairs associated with orthodontic treatment.

004.02(I) ADJUNCTIVE GENERAL SERVICES.
004.02(I)(i) PALLIATIVE TREATMENT. Palliative treatment is covered once per date of service per location. Palliative treatment on a specific tooth is not covered if definitive treatment was provided on the same tooth for the same date of service.
004.02(I)(i)(1) DOCUMENTATION REQUIREMENTS. Providers must document the palliative treatment provided on or in the dental claim, and in the dental chart.

004.02(I)(ii) GENERAL ANESTHESIA. General anesthesia administered in the provider's office is covered when it is medically necessary to treat the client. Administration of general anesthesia must be performed in full compliance with Neb. Rev. Stat. § 38-101 to § 38-1142.
004.02(I)(ii)(1) DOCUMENTATION REQUIREMENTS. Providers must document in the dental chart the medical necessity for the anesthesia. An appropriate sedation record must be maintained, including the names of all drugs administered, including local anesthetics, dosages, and monitored vital signs.

004.02(I)(iii) ANALGESIA, ANXIOLYSIS, AND INHALATION OF NITROUS OXIDE. Analgesia, anxiolysis, and inhalation of nitrous oxide is covered when medically necessary to treat the client.

004.02(I)(iv) INTRAVENOUS SEDATION AND ANALGESIA. Intravenous sedation and analgesia administered in the provider's office or location is covered when it is medically necessary to treat the client.
004.02(I)(iv)(1) DOCUMENTATION REQUIREMENTS. Providers must document in the dental chart the medical need for the anesthesia. An appropriate sedation record must be maintained, including the names of all drugs administered, including local anesthetics, dosages, and monitored vital signs.

004.02(I)(v) NON-INTRAVENOUS CONSCIOUS SEDATION. Non-intravenous conscious sedation administered in the provider's office is covered when it is medically necessary to treat the client. The use of oral medications require monitoring.
004.02(I)(v)(1) DOCUMENTATION REQUIREMENTS. Providers must document in the dental chart the medical need for the anesthesia. An appropriate sedation record must be maintained, including the names of all drugs administered, local anesthetics, dosages, and monitored vital signs.

004.02(I)(vi) HOUSE CALL, NURSING FACILITY CALL, HOSPITAL CALL, AND AMBULATORY SURGICAL CENTER (ASC) CALL. House call, nursing facility call, hospital call, and ambulatory surgical center call is covered one per day per facility regardless of the number of patients seen.
004.02(I)(vi)(1) DOCUMENTATION REQUIREMENTS. Providers must document on or in the dental claim the name of the facility, or home address where treatment was provided.

004.02(I)(vii) OFFICE VISIT AFTER REGULARLY SCHEDULED HOURS. Office visit after regularly scheduled hours is covered in addition to an exam and treatment provided, when treatment is provided after normal office hours.

004.02(I)(viii) OCCLUSAL GUARD. Occlusal guard is covered once every 1095 days to minimize the effects of bruxism and other occlusal factors. Occlusal guards are removable appliances. Athletic guards are not covered.
004.02(I)(viii)(1) DOCUMENTATION REQUIREMENTS. Providers must document the medical necessity for the occlusal guard in the dental chart. Documentation should support evidence of significant loss of tooth enamel or tooth chipping, or the medical documentation supports headaches and jaw pain.

004.03 NON-COVERED SERVICES. Medicaid does not cover any service that is:

(A) Cosmetic;

(B) More costly than another, equally effective available service;

(C) Not within the coverage criteria of these regulations;

(D) Determined not medically necessary by the Department; or

(E) Experimental, investigational, or non-Food and Drug Administration (FDA) approved.

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