Current through Register Vol. 24-18, September 15, 2024
Clients described in WAC
182-535-1060
are eligible for the dental-related preventive services listed in this section,
subject to coverage limitations and client-age requirements identified for a
specific service.
(1)
Prophylaxis. The medicaid agency covers prophylaxis as follows.
Prophylaxis:
(a) Includes scaling and
polishing procedures to remove coronal plaque, calculus, and stains when
performed on tooth structures and implants.
(b) Is limited to once every:
(i) Six months for clients:
(A) Age 18 and younger; or
(B) Of any age residing in an alternate
living facility or nursing facility;
(ii) Twelve months for clients age 19 and
older.
(c) Is reimbursed
according to (b) of this subsection when the service is performed:
(i) At least six months after periodontal
scaling and root planing, or periodontal maintenance services, for clients:
(A) Age 13 through 18; or
(B) Of any age residing in an alternate
living facility or nursing facility; or
(ii) At least 12 months after periodontal
scaling and root planing, periodontal maintenance services, for clients age 19
and older.
(d) Is not
reimbursed separately when performed on the same date of service as periodontal
scaling and root planing, periodontal maintenance, gingivectomy, gingivoplasty,
or scaling in the presence of generalized moderate or severe gingival
inflammation.
(e) Is covered for
clients of the developmental disabilities administration of the department of
social and health services (DSHS) according to (a), (c), and (d) of this
subsection and WAC
182-535-1099.
(2)
Topical fluoride treatment.
The agency covers the following per client, per provider or clinic:
(a) Fluoride rinse, foam or gel, fluoride
varnish, including disposable trays, three times within a 12-month period with
a minimum of 110 days between applications for clients:
(i) Age six and younger;
(ii) During orthodontic treatment.
(b) Fluoride rinse, foam or gel,
fluoride varnish, including disposable trays, two times within a 12-month
period with a minimum of 170 days between applications for clients:
(i) From age seven through 18; or
(ii) Of any age residing in alternate living
facilities or nursing facilities.
(c) Fluoride rinse, foam or gel, fluoride
varnish, including disposable trays, for clients age 19 and older, once within
a 12-month period.
(d) Additional
topical fluoride applications only on a case-by-case basis and when prior
authorized.
(e) Topical fluoride
treatment for clients of the developmental disabilities administration of DSHS
according to WAC
182-535-1099.
(3)
Silver diamine fluoride.
(a) The agency covers silver diamine fluoride
as follows:
(i) When used for stopping the
progression of caries or as a topical preventive agent;
(ii) Allowed two times per client per tooth
in a 12-month period; and
(iii)
Cannot be billed with interim therapeutic restoration on the same tooth when
arresting caries or as a preventive agent.
(b) The dental provider or office must have a
signed informed consent form on file for each client receiving a silver diamine
fluoride application. The form must include the following:
(i) Benefits and risks of silver diamine
fluoride application;
(ii)
Alternatives to silver diamine fluoride application; and
(iii) A color photograph example that
demonstrates the post-procedure blackening of a tooth with silver diamine
fluoride application.
(4)
Oral hygiene instruction.
Includes instruction for home care such as tooth brushing technique, flossing,
and use of oral hygiene aids. Oral hygiene instruction is included as part of
the global fee for prophylaxis for clients age nine and older. The agency
covers individualized oral hygiene instruction for clients age eight and
younger when all of the following criteria are met:
(a) Only once per client every six months
within a 12-month period.
(b) Only
when not performed on the same date of service as prophylaxis or within six
months from a prophylaxis by the same provider or clinic.
(c) Only when provided by a licensed dentist
or a licensed dental hygienist and the instruction is provided in a setting
other than a dental office or clinic.
(5)
Tobacco/nicotine cessation
counseling for the control and prevention of oral disease. The agency
covers tobacco/nicotine cessation counseling for pregnant individuals only. See
WAC
182-531-1720.
(6)
Sealants. The agency covers:
(a) Sealants for clients age 20 and younger
and clients any age of the developmental disabilities administration of
DSHS.
(b) Sealants once per tooth:
(i) In a three-year period for clients age 20
and younger; and
(ii) In a two-year
period for clients any age of the developmental disabilities administration of
DSHS according to WAC
182-535-1099.
(c) Sealants only when used on the occlusal
surfaces of:
(i) Permanent teeth two, three,
14, 15, 18, 19, 30, and 31; and
(ii) Primary teeth A, B, I, J, K, L, S, and
T.
(d) Sealants on
noncarious teeth or teeth with incipient caries.
(e) Sealants only when placed on a tooth with
no preexisting oc-clusal restoration, or any occlusal restoration placed on the
same day.
(f) Sealants are included
in the agency's payment for occlusal restoration placed on the same
day.
(g) Additional sealants not
described in this subsection on a case-by-case basis and when prior
authorized.
(7)
Space maintenance. The agency covers:
(a) One fixed unilateral space maintainer per
quadrant or one fixed bilateral space maintainer per arch, including
recementation, for missing primary molars A, B, I, J, K, L, S, and T, when:
(i) Evidence of pending permanent tooth
eruption exists; and
(ii) The
service is not provided during approved orthodontic treatment.
(b) Replacement space maintainers
on a case-by-case basis when authorized.
(c) The removal of fixed space maintainers
when removed by a different provider.
(i)
Space maintainer removal is allowed once per appliance.
(ii) Reimbursement for space maintainer
removal is included in the payment to the original provider that placed the
space maintainer.
Statutory Authority:
RCW
41.05.021. 12-09-081, §182-535-1082,
filed 4/17/12, effective 5/18/12. 11-14-075, recodified as §182-535-1082,
filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090,
74.09.500,
74.09.520. 07-06-042, §
388-535-1082, filed 3/1/07, effective
4/1/07.
