Current through Register No. 40, October 3, 2024
(a) The following dental services shall be
covered for recipients who are under 21 years of age:
(1) Prophylaxis, no more frequently than
every 150 days;
(2) Restorative
treatment;
(3) Periodic
examinations, no more frequently than every 150 days, unless they are medically
necessary to diagnose an illness or condition;
(4) Vital pulpotomy, which consists of
removal of diseased or involved pulp in an effort to retain the remaining pulp
in a healthy, vital condition;
(5)
Extractions of symptomatic teeth associated with diagnosed pathology, such as
tumor, cyst, or infection, except third molars as described in (7)
below;
(6) Extractions of
asymptomatic teeth, except third molars as described in (7) below, subject to
prior authorization in accordance with
He-W 566.07,
as follows:
a. When associated with diagnosed
pathology, such as tumor, cyst, or infection; or
b. When extraction is part of an orthodontic
treatment plan that has been approved through prior authorization by the
department in accordance with
He-W
566.07;
(7) Third molar extraction, subject to prior
authorization in accordance with
He-W
566.07;
(8) General anesthesia when medically
necessary and documented in the recipient's dental records;
(9) Nitrous oxide analgesia and intravenous
therapy sedation;
(10)
Comprehensive orthodontic treatment for severe handicapping malocclusion in
accordance with
He-W
566.05(a), subject to prior
authorization in accordance with
He-W
566.07;
(11) Interceptive orthodontic treatment in
accordance with
He-W
566.05(b), subject to prior
authorization in accordance with
He-W
566.07;
(12) Space maintainers when medically
necessary to replace a prematurely lost deciduous or permanent molar or
bicuspid;
(13) Limited orthodontic
treatment in accordance with
He-W
566.05(c);
(14) Radiographs as follows:
a. Complete series or panographic survey,
once every 5 years;
b. Bitewings
every 12 months if medically necessary; and
c. All types of dental radiographs regardless
of limits in a. and b. above, as may be required to complete a differential
diagnosis;
(15)
Palliative treatment when the claim is submitted in accordance with
He-W
566.10(f);
(16) Removable prosthetic replacement of
permanent teeth subject to prior authorization in accordance with
He-W
566.07;
(17) Topical fluoride treatment applied twice
per year until age 21;
(18) If
moderate or high risk of caries is documented, 2 applications of silver diamine
per tooth, provided that no more than 18 total silver diamine treatments shall
be administered per year and no application of silver diamine shall be
administered after the recipient reaches the age of 21;
(19) Endodontia, including root canal
therapy, excluding third molars, when the claim is accompanied by a radiograph,
and the endodontia treatment is deemed complete when all radiographs
demonstrate that the canals are completely filled to the apex of the root(s) of
the tooth in accordance with
He-W
566.10(e);
(20) Crowns;
(21) Periodontal treatment limited to
prophylaxis, scaling, and root planing;
(22) Surgical periodontal treatment subject
to prior authorization in accordance with
He-W
566.07;
(23) Sealants for permanent and deciduous
molars every 5 years, until age 21;
(24) Diagnostic and preventive dental
services, with the exception of orthodontic treatment as allowed in (b) below,
available for EPSDT-eligible children in accordance with
He-W 546.05;
and
(25) Other services determined
by the department to be medically necessary, in accordance with
He-W
546.06.
(b) Orthodontic treatment for malocclusions
that do not meet the criteria set forth in
He-W
566.05(b) shall be considered for
orthodontic treatment under the EPSDT prior authorization for coverage based on
medical necessity provisions at He-W 546 when documentation of the following is
submitted to the department:
(1) Principal
diagnosis;
(2) Prognosis with and
without treatment;
(3) Date of
onset of the illness or condition and etiology, if known;
(4) Clinical significance or functional
impairment or pathology caused by the illness or condition resulting from the
malocclusion;
(5) Demonstration of
evidence of the degree to which the malocclusion contributes to the illness or
condition;
(6) Specific types of
services to be rendered by each discipline associated with the total treatment
plan;
(7) Therapeutic goals to be
achieved by each discipline and anticipated time for achievement of
goals;
(8) Explanation of any
existing conditions that are likely to limit efficacy of treatment;
(9) Extent to which health care services have
been previously provided to address the illness or condition and summary of
results demonstrated by prior care;
(10) Orthodontic records as described in
He-W 566.05(g)(1), (2) and
(4); and
(11) Any additional documentation in
accordance with
He-W
546.06(b) or any other documentation
available which might assist in making a determination of medical necessity of
the proposed orthodontic treatment.
(c) The documentation submitted in accordance
with (b) above shall be completed by health professionals who are sufficiently
trained and duly licensed to diagnose and treat the illness or condition
arising from the malocclusion and creating the medical necessity for treatment.
(d) The documentation described in
(b) and (c) above shall be submitted to the department by the medicaid enrolled
provider who will complete the orthodontic treatment along with a request for
prior authorization in accordance with
He-W
546.06.
(e) The following dental services shall be
covered for recipients 21 years of age or over for relief of acute pain or
elimination of acute infection or diagnosed pathology:
(1) Palliative treatment when the claim is
submitted in accordance with
He-W
566.10(f);
(2) Extraction of the causative tooth or
teeth and biopsy of the tooth or teeth;
(3) Treatment of severe trauma, when a
determination is made by the attending clinician using standard medical
parameters for emergency conditions, which shall include, but not be limited
to:
a. Hemorrhage;
b. Laceration requiring suturing;
c. Abrasion requiring debridement;
or
d. Bone fracture requiring
reduction; and
(4)
Radiographs and examinations as necessary to assess conditions described in
(1)-(3) above.
(See Revision Note at chapter heading He-W 500); ss by
#5639, eff 6-17-93; ss by #7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by
#9902, eff 6-1-11
