130 CMR, § 420.423

Current through Register 1533, October 25, 2024

Section 420.423 - Service Descriptions and Limitations: Radiographs

(A)Introduction and Definitions.

(1) The MassHealth agency pays for radiographs/diagnostic imaging taken as an integral part of diagnosis and treatment planning.

(a)Assessing Extent of Required Radiographs. Providers should conduct a clinical examination; consider the member's oral and medical histories, as well as the member's vulnerability to environmental factors that may affect the oral health before conducting a radiographic examination to determine the type of imaging, frequency, and number of images. Radiographs should be taken only when there is an expectation that the diagnostic yield will affect patient care. The intent is to confine radiation exposure of members to the minimum necessary to achieve satisfactory diagnosis.

(b) The provider must document efforts to obtain any previous radiographs/diagnostic imaging before prescribing more.

(c) When radiographs and diagnostic imaging submitted to the MassHealth agency as part of the prior authorization process or upon other request are not of good diagnostic quality, the provider may not claim payment for any retake of radiographs/diagnostic imaging requested by the MassHealth agency.

(2)Definitions.

(a)Bitewing Radiographs - a bitewing radiograph is a diagnostic image showing the crowns of the upper and lower teeth and alveolar bone simultaneously.

(b)Cephalometric Radiograph - a 2D image of the head made using Cephalostat to standardize anatomic, positioning, and with reproducible X-ray beam geometry.

(c)Intraoral Complete Series of Radiographic Images - intraoral complete series of radiographic images surveys the whole mouth; usually consists of 14 through 22 periapical and posterior bitewing images, intended to display the crowns and roots of all teeth, periapical areas, and alveolar bone.

(d)Periapical Radiographs - diagnostic intraoral images showing tooth apices and surrounding structures in a particular intraoral area.

(e)Occlusal Radiographs - a supplementary radiograph designed to provide a more extensive view of the maxilla and mandible; highlighting tooth development and placement in children.

(f)Panoramic Radiograph - an extraoral image showing a two-dimensional view of the patients' entire jaw from ear to ear.

(B)Intraoral Conventional or Direct Digital Radiographs.

(1)Intraoral Complete Series of Radiographic Images. The MassHealth agency pays for intraoral complete series of radiographic images once every three calendar years per member; per provider or location. Intraoral complete series of radiographic images are recommended for members with clinical evidence of generalized oral disease or a history of extensive dental treatment. The MassHealth agency allows for substitution of the intraoral complete series of radiographic images with individualized radiographs consisting of posterior bitewings with a panoramic or occlusal radiograph and selected periapicals for members with transitional dentition. Panoramic radiographs cannot be substituted for intraoral complete series of radiographic images if intraoral complete series of radiographic images are required for a prior authorization request, unless the member has complete bony impacted teeth, or other surgical conditions listed under 130 CM 420.423(C)(1), and is edentulous. The MassHealth agency does not pay more for individual periapical radiographs (with or without bitewings) than it would for an intraoral complete series of radiographic images. The MassHealth agency further defines the numbers of radiographs which constitute intraoral complete series of radiographic images based on age limitations described in Appendix E of the Dental Manual.

(2)Bitewing Radiographs. The MassHealth agency pays for up to four bitewing radiographs as separate procedures based on the clinical guidelines set forth by the American Dental Association. Providers must document variations from the ADA clinical guidelines in the member's dental record. The MassHealth agency does not pay separately for bitewing radiographs taken as part of an intraoral complete series of radiographic images.

(3)Periapical Radiographs. Periapical radiographs may be taken for specific areas where extraction is anticipated, or when infection, periapical change, or an anomaly is suspected, or when otherwise directed by the MassHealth agency. A maximum of four periapical radiographs is allowed per day, per member per provider, or location.

(4)Occlusal Radiographs. The MassHealth agency pays for two occlusal radiographs per calendar year per member younger than five years old per provider or location.

(5)Panoramic Radiographs. The MassHealth agency pays for panoramic radiographs for surgical and nonsurgical conditions as described in 130 CMR 420.423(C)(1) and (2). The MassHealth agency does not pay for panoramic radiographs for orthodontics, crowns, endodontics, periodontics, and interproximal caries.

(6)Cephalometric Radiographs. The MassHealth agency pays for cephalometric radiographs in conjunction with surgical conditions including, but not limited to, status after facial trauma, mandibular fractures, dentoalveolar fractures, mandibular atrophy, and jaw dislocations. Payment for cephalometric radiographs, or other radiographs, in conjunction with orthodontic diagnosis is included in the payment for orthodontic services (see 130 CMR 420.431(C)(9)) . The MassHealth agency does not pay separately for additional radiographs when required for orthodontic diagnosis.

(C)Surgical Conditions. The MassHealth agency pays for panoramic radiographs when used as a diagnostic tool for surgical conditions, whether or not the radiograph is taken prior to the procedure or on the same date as the surgical procedure. Surgical conditions include, but are not limited to,

(1) impactions;

(2) teeth requiring extractions in more than one quadrant;

(3) large cysts or tumors that are not fully visualized by intraoral radiographs or clinical examination;

(4) salivary-gland disease;

(5) maxillary-sinus disease;

(6) facial trauma;

(7) trismus where an intraoral radiographs placement is impossible; and

(8) orthognathic surgery.

(D)Nonsurgical Conditions.

(1)Members Younger than 21 Years Old. The MassHealth agency pays for only one panoramic radiograph every three calendar years per member for nonsurgical conditions, to monitor the growth and development of permanent dentition as a part of an individualized radiograph series for the child member with transitional dentition.

(2)Members 21 Years of Age or Older. The MassHealth agency pays for only one panoramic radiograph every three years per member in lieu of an intraoral complete series of radiographic images only for those members who are unable to cooperate with the process for obtaining an intraoral complete series of radiographic images or are edentulous. The provider must document in the member's dental record the reasons the member cannot cooperate with the process for obtaining an intraoral complete series of radiographic images.