Current through Register Vol. 24-18, September 15, 2024
Clients described in WAC
182-535-1060
are eligible to receive the oral and maxillofacial surgery services listed in
this section, subject to the coverage limitations, restrictions, and clientage
requirements identified for a specific service.
(1)
Oral and maxillofacial surgery
services. The medicaid agency:
(a)
Requires enrolled providers who do not meet the conditions in WAC
182-535-1070(3)
to bill claims for services that are listed in this subsection using only the
current dental terminology (CDT) codes.
(b) Requires enrolled providers (oral and
maxillofacial surgeons) who meet the conditions in WAC
182-535-1070(3)
to bill claims using current procedural terminology (CPT) codes unless the
procedure is specifically listed in the agency's current published billing
guide as a CDT covered code (e.g., extractions).
(c) Covers nonemergency oral surgery
performed in a hospital or ambulatory surgery center only for:
(i) Clients age eight and younger;
(ii) Clients age nine through twenty. Prior
authorization is required for the site of service; and
(iii) Clients any age of the developmental
disabilities administration of the department of social and health services
(DSHS).
(d) For
site-of-service and oral surgery CPT codes that require prior authorization,
the agency requires the dental provider to submit current records (within the
past twelve months), including:
(i)
Documentation used to determine medical appropriateness;
(ii) Cephalometric films;
(iii) Radiographs (X-rays);
(iv) Photographs; and
(v) Written narrative/letter of medical
necessity, including proposed billing codes.
(e) Requires the client's dental record to
include supporting documentation for each type of extraction or any other
surgical procedure billed to the agency. The documentation must include:
(i) Appropriate consent form signed by the
client or the client's legal representative;
(ii) Appropriate radiographs;
(iii) Medical justification with
diagnosis;
(iv) Client's blood
pressure, when appropriate;
(v) A
surgical narrative and complete description of each service performed beyond
surgical extraction or beyond code definition;
(vi) A copy of the post-operative
instructions; and
(vii) A copy of
all pre- and post-operative prescriptions.
(f) Covers simple and surgical
extractions.
(g) Covers unusual,
complicated surgical extractions with prior authorization.
(h) Covers tooth reimplantation/stabilization
of accidentally evulsed or displaced teeth.
(i) Covers surgical extraction of unerupted
teeth.
(j) Covers debridement of a
granuloma or cyst that is five millimeters or greater in diameter. The agency
includes debridement of a granuloma or cyst that is less than five millimeters
as part of the global fee for the extraction.
(k) Covers biopsy of soft oral tissue, brush
biopsy, and surgical excision of soft tissue lesions. Providers must keep all
biopsy reports or findings in the client's dental record.
(l) Covers only the following excisions of
bone tissue in conjunction with placement of complete or partial dentures:
(i) Removal of lateral exostosis;
(ii) Removal of torus palatinus or torus
mandibularis;
(iii) Surgical
reduction of osseous tuberosity.
(2)
Alveoloplasty. The agency
covers alveoloplasty only in conjunction with the preparation of dentures or
partials. Documentation supporting the medical necessity for the procedure must
be maintained in the client's record. Supporting documentation must include
current radiographs and medical justification narrative.
(3)
Surgical incisions. The
agency covers the following surgical incision-related services:
(a) Uncomplicated intraoral and extraoral
soft tissue incision and drainage of abscess. The agency does not cover this
service when combined with an extraction or root canal treatment. Documentation
supporting the medical necessity must be in the client's record.
(b) Removal of foreign body from mucosa,
skin, or subcutaneous alveolar tissue. Documentation supporting the medical
necessity for the service must be in the client's record.
(c) Frenuloplasty/frenulectomy for clients
age six and younger, without prior authorization.
(d) Frenuloplasty/frenulectomy for clients
age seven through twelve. Prior authorization is required. Photos must be
submitted to the agency with the prior authorization request. Documentation
supporting the medical necessity for the service must be in the client's
record.
(e) Surgical access of
unerupted teeth for clients age twenty and younger. Prior authorization is
required.
(4)
Occlusal orthotic devices. (Refer to WAC 182-5351098 (4)(c) for
occlusal guard coverage and limitations on coverage.) The agency covers:
(a) Occlusal orthotic devices for clients age
twelve through twenty. Prior authorization is required.
(b) An occlusal orthotic device only as a
laboratory processed full arch appliance.
Statutory Authority:
RCW
41.05.021. 12-09-081, §182-535-1094,
filed 4/17/12, effective 5/18/12. 11-14-075, recodified as §182-535-1094,
filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090,
74.09.500,
74.09.520. 07-06-042, §
388-535-1094, filed 3/1/07, effective
4/1/07.
