Current through Register Vol. 24-18, September 15, 2024
Subject to coverage limitations and restrictions identified
for a specific service, the medicaid agency pays for the additional
dental-related services listed in this section that are provided to clients of
the developmental disabilities administration of the department of social and
health services (DSHS), regardless of age.
(1)
Preventive services. The
agency covers:
(a) Periodic oral evaluations
once every four months per client, per provider.
(b) Prophylaxis once every four
months.
(c) Periodontal maintenance
once every six months (see subsection (3) of this section for limitations on
periodontal scaling and root planing).
(d) Topical fluoride varnish, rinse, foam or
gel, once every four months, per client, per provider or clinic.
(e) Sealants (see WAC
182-535-1082
for sealant coverage):
(i) Only when used on
the occlusal surfaces of:
(A) Primary teeth A,
B, I, J, K, L, S, and T; or
(B)
Permanent teeth two, three, four, five, twelve, thirteen, fourteen, fifteen,
eighteen, nineteen, twenty, twenty-one, twenty-eight, twenty-nine, thirty, and
thirty-one.
(ii) Once
per tooth in a two-year period.
(2)
Other restorative services.
The agency covers:
(a) All recementations of
permanent indirect crowns.
(b)
Prefabricated stainless steel crowns, including stainless steel crowns with
resin window, resin-based composite crowns (direct), prefabricated esthetic
coated stainless steel crowns, and prefabricated resin crowns for primary
anterior teeth once every two years only for clients age twenty and younger
without prior authorization.
(c)
Prefabricated stainless steel crowns, including stainless steel crowns with
resin window, resin-based composite crowns (direct), prefabricated esthetic
coated stainless steel crowns, and prefabricated resin crowns for primary
posterior teeth once every two years for clients age twenty and younger without
prior authorization if:
(i) Decay involves
three or more surfaces for a primary first molar;
(ii) Decay involves four or more surfaces for
a primary second molar; or
(iii)
The tooth had a pulpotomy.
(d) Prefabricated stainless steel crowns,
including stainless steel crowns with resin window, and prefabricated resin
crowns for permanent posterior teeth excluding one, sixteen, seventeen, and
thirty-two once every two years without prior authorization for any
age.
(3)
Periodontic services.
(a)
Surgical periodontal services. The agency covers:
(i) Gingivectomy/gingivoplasty once every
three years. Documentation supporting the medical necessity of the service must
be in the client's record (e.g., drug induced gingival hyperplasia).
(ii) Gingivectomy/gingivoplasty with
periodontal scaling and root planing or periodontal maintenance when the
services are performed:
(A) In a hospital or
ambulatory surgical center; or
(B)
For clients under conscious sedation, deep sedation, or general
anesthesia.
(b)
Nonsurgical periodontal
services. The agency covers:
(i)
Periodontal scaling and root planing, one time per quadrant in a twelve-month
period.
(ii) Periodontal
maintenance (four quadrants) substitutes for an eligible periodontal scaling or
root planing, twice in a twelve-month period.
(iii) Periodontal maintenance allowed six
months after scaling or root planing.
(iv) Full-mouth or quadrant debridement
allowed once in a twelve-month period.
(v) Full-mouth scaling in the presence of
generalized moderate or severe gingival inflammation allowed once in a
twelve-month period.
(4)
Adjunctive general services.
The agency covers:
(a) Oral parenteral
conscious sedation, deep sedation, or general anesthesia for any dental
services performed in a dental office or clinic. Documentation supporting the
medical necessity must be in the client's record.
(b) Sedation services according to WAC
182-535-1098(1)(c)
and (e).
(5)
Nonemergency dental
services. The agency covers nonemergency dental services performed in a
hospital or an ambulatory surgical center for services listed as covered in WAC
182-535-1082,
182-535-1084,
182-535-1086,
182535-1088, and 182-535-1094. Documentation supporting the medical necessity
of the service must be included in the client's record.
(6)
Miscellaneous services - Behavior
management. The agency covers behavior management according to WAC
182-535-1098.
Statutory Authority:
RCW
41.05.021. 12-09-081, §182-535-1099,
filed 4/17/12, effective 5/18/12. 11-14-075, recodified as §182-535-1099,
filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090,
74.09.500,
74.09.520. 07-06-042, §
388-535-1099, filed 3/1/07, effective
4/1/07.
