130 CMR, § 420.425

Current through Register 1530, September 13, 2024

Section 420.425 - Service Descriptions and Limitations: Restorative Services

The MassHealth agency pays for restorative services in accordance with the service descriptions and limitations in 130 CMR 420.425(A) through (E). The MassHealth agency considers all of the following to be components of a completed restoration (local anesthesia tooth preparation, acid etching, all adhesives applications, resin bonding agents, amalgam bonding agents, liners, bases, amalgams, resin-based composites, glass ionomers, curing and polishing) and includes them in the payment for this service. The MassHealth agency does not pay for composite or amalgam restorations replaced within one year of the date of completion of the original restoration when replaced by the same provider or dental group. The initial payment includes all restorations replaced due to defects or failure less than one year from the original placement.

(A)Amalgam Restorations. The MassHealth agency does not pay for restorations on primary teeth when early exfoliation (more than ²/₃ of the root structure resorbed) is expected.

(B)Resin-based Composite Restorations.

(1) The MassHealth agency pays for:

(a) all resin-based composite restorations for all surfaces of anterior and posterior teeth; and

(b) full-coverage composite crowns only for members younger than 21 years old, only for anterior primary teeth.

(2) For anterior teeth, the MassHealth agency pays no more than the maximum allowable payment for four-or-more-surface resin-based composite restorations on the same tooth, except for reinforcing pins.

(3) The MassHealth agency pays for only one resin-based composite restoration per member per tooth surface per 12 months per provider or provider location.

(4) The MassHealth agency does not pay more for a composite restoration on a posterior (primary or permanent) tooth than it would for an amalgam restoration.

(C)Crowns, Posts and Cores.

(1)Members Younger than 21 Years Old. The MassHealth agency pays for the following crown materials on permanent incisors, cuspids, bicuspids, and first and second molars:

(a) crowns made from resin-based composite (indirect);

(b) crowns porcelain-fused to predominantly base metal;

(c) crowns porcelain-fused to high noble metal;

(d) crowns made from porcelain or ceramic;

(e) crowns porcelain-fused to semi-precious metal;

(f) full case high noble metal;

(g) posts and cores and/or pin retention; and

(h) prefabricated porcelain/ceramic crown - primary tooth; and

(i) prefabricated stainless steel crowns for primary and permanent posterior teeth or prefabricated resin crowns for primary and permanent anterior teeth. Stainless steel or prefabricated resin crowns are limited to instances where the prognosis is favorable and must not be placed on primary teeth that are mobile or show advanced resorption of roots. The MassHealth agency pays for no more than four stainless steel or prefabricated resin crowns per member per date of service, except in cases that are treated in a hospital operating room or ambulatory care center.

(2)Members 21 Years of Age and Older. The MassHealth agency pays for the following crown materials on permanent incisors, cuspids, bicuspids, and first and second molars:

(a) crowns porcelain fused to predominantly base metal;

(b) crowns made from porcelain or ceramic;

(c) stainless steel crowns only if crown porcelain fused to predominately base metal is unsuitable and extraction (the alternative treatment) would cause undue medical risk for a member with one or more medical conditions that include, but are not limited to,

1. hemophilia;

2. history of radiation therapy;

3. acquired or congenital immune disorder;

4. severe physical disabilities such as quadriplegia;

5. profound intellectual or developmental disabilities; or

6. profound mental illness; and

(d) posts and cores and/or pin retention.

(D)Reinforcing Pins . The MassHealth agency pays for reinforcing pins only when used in conjunction with a two-or-more-surface restoration on a permanent tooth. Commercial amalgam bonding systems are included in this category.

(E)Crown or Bridge Repair. The MassHealth agency pays for chairside crown repair for all members and fixed partial denture repair only for members younger than 21 years old. A description of the repair must be documented in the member's dental record. The MassHealth agency pays for unspecified restoration procedures for crown repair by an outside laboratory only if the repair is extensive and cannot be done chairside.