Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-535 - Dental-related services
GENERAL
Section 182-535-1088 - Dental-related services-Covered-Periodontic services
Universal Citation: WA Admin Code 182-535-1088
Current through Register Vol. 24-18, September 15, 2024
Clients described in WAC 182-535-1060 are eligible to receive the dental-related periodontic services listed in this section, subject to coverage limitations, restrictions, and client-age requirements identified for a specified service.
(1) Surgical periodontal services. The medicaid agency covers the following surgical periodontal services, including all postoperative care:
(a) Gingivectomy/gingivoplasty (does not
include distal wedge procedures on erupting molars) only on a case-by-case
basis and when prior authorized and only for clients age 20 and younger;
and
(b) Gingivectomy/gingivoplasty
(does not include distal wedge procedures on erupting molars) for clients of
the developmental disabilities administration of the department of social and
health services (DSHS) according to WAC
182-535-1099.
(2) Nonsurgical periodontal services. The agency:
(a) Covers
periodontal scaling and root planing for clients age 13 through 18, once per
quadrant per client, in a two-year period on a case-by-case basis, when prior
authorized, and only when:
(i) The client has
radiographic evidence of periodontal disease;
(ii) The client's record includes supporting
documentation for the medical necessity, including complete periodontal
charting done within the past 12 months from the date of the prior
authorization request and a definitive diagnosis of periodontal
disease;
(iii) The client's
clinical condition meets current published periodontal guidelines;
and
(iv) Performed at least two
years from the date of completion of periodontal scaling and root planing or
surgical periodontal treatment, or at least 12 calendar months from the
completion of periodontal maintenance.
(b) Covers periodontal scaling and root
planing once per quadrant per client in a two-year period for clients age 19
and older. Criteria in (a)(i) through (iv) of this subsection must be
met.
(c) Considers ultrasonic
scaling, gross scaling, or gross debridement to be included in the procedure
and not a substitution for periodontal scaling and root planing.
(d) Covers periodontal scaling and root
planing only when the services are not performed on the same date of service as
prophylaxis, periodontal maintenance, gingivectomy, or gingivoplasty.
(e) Covers periodontal scaling and root
planing for clients of the developmental disabilities administration of DSHS
according to WAC
182-535-1099.
(f) Covers periodontal scaling and root
planing, one time per quadrant in a 12-month period for clients residing in an
alternate living facility or nursing facility.
(3) Other periodontal services. The agency:
(a) Covers periodontal
maintenance for clients age 13 through 18 once per client in a 12-month period
on a case-by-case basis, when prior authorized, and only when:
(i) The client has radiographic evidence of
periodontal disease;
(ii) The
client's record includes supporting documentation for the medical necessity,
including complete periodontal charting done within the past 12 months with
location of the gingival margin and clinical attachment loss and a definitive
diagnosis of periodontal disease;
(iii) The client's clinical condition meets
current published periodontal guidelines; and
(iv) The client has had periodontal scaling
and root planing but not within 12 months of the date of completion of
periodontal scaling and root planing, or surgical periodontal
treatment.
(b) Covers
periodontal maintenance once per client in a twelve month period for clients
age 19 and older. Criteria in (a)(i) through (iv) of this subsection must be
met.
(c) Covers periodontal
maintenance only if performed at least 12 calendar months after receiving
prophylaxis, periodontal scaling and root planing, gingivectomy, or
gingivoplasty.
(d) Covers
periodontal maintenance for clients of the developmental disabilities
administration of DSHS according to WAC
182-535-1099.
(e) Covers periodontal maintenance for
clients residing in an alternate living facility or nursing facility:
(i) Periodontal maintenance (four quadrants)
substitutes for an eligible periodontal scaling or root planing once every six
months.
(ii) Periodontal
maintenance allowed six months after scaling or root planing.
(f) Covers periodontal maintenance
for clients 21 and older with a diagnosis of diabetes:
(i) Periodontal maintenance allowed once
every three months. Criteria in (a)(i) through (iii) of this subsection must be
met.
(ii) Periodontal maintenance
allowed three months after scaling or root planing.
(g) Covers full-mouth scaling in the presence
of generalized moderate or severe gingival inflammation and only:
(i) For clients age 19 and older once in a
12-month period after an oral evaluation; and
(ii) For clients age 13 through 18 once in a
12-month period after an oral evaluation and when prior authorized.
Statutory Authority: RCW 41.05.021. 12-09-081, §182-535-1088, filed 4/17/12, effective 5/18/12. 11-14-075, recodified as §182-535-1088, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1088, filed 3/1/07, effective 4/1/07.
Disclaimer: These regulations may not be the most recent version. Washington may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
