10 Colo. Code Regs. § 2505-10-8.201

Current through Register Vol. 47, No. 16, August 25, 2024

Section 10 CCR 2505-10-8.201 - ADULT DENTAL SERVICES

8.201.1DEFINITIONS

A. Adult Client means an individual who is 21 years or older and eligible for medical assistance benefits.

B. Comprehensive Oral Evaluation - New or Established Patient means a thorough evaluation and documentation of a client's dental and medical history to include extra-oral and intra-oral hard and soft tissues, dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, and oral cancer screening, as defined by the Current Dental Terminology (CDT).

C. Comprehensive Periodontal Evaluation means the procedure that is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the patient's dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation, as defined by the CDT.

D. Dental Caries is a common chronic infectious transmissible disease resulting from tooth-adherent specific bacteria that metabolize sugars to produce acid which demineralizes tooth structure over time (tooth decay).

E. Dental professional means a licensed dentist, dental hygienist, or dental therapist enrolled with Colorado Medicaid.

F. Detailed and Extensive Oral Evaluation - Problem Focused, By Report means a detailed and extensive problem focused evaluation entailing extensive diagnostic and cognitive modalities based on the findings of a comprehensive oral evaluation. Integration of more extensive diagnostic modalities to develop a treatment plan for a specific problem is required. The condition requiring this type of evaluation shall be described and documented. Examples of conditions requiring this type of evaluation may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain of unknown origin, conditions requiring multi-disciplinary consultation, etc., as defined by the CDT.

G. Diagnostic Imaging means a visual display of structural or functional patterns for the purpose of diagnostic evaluation, as defined by the CDT.

H. Endodontic services means services which are concerned with the morphology, physiology and pathology of the human dental pulp and periradicular tissues.

I. Emergency Services means the need for immediate intervention by a physician, osteopath or dental professional to stabilize an oral cavity condition.

J. Evaluation means a patient assessment that may include gathering of information through interview, observation, examination, and use of specific tests that allows a dentist to diagnose existing conditions, as defined by the CDT.

K. High Risk of Caries is indicated in Adult Clients who present with demonstrable caries, a history of restorative treatment, dental plaque, and enamel demineralization.

L. Immediate Intervention or Treatment is when a patient presents with symptoms and/or complaints of pain, infection or other conditions that would require immediate attention.

M. Limited Oral Evaluation - Problem Focused means an evaluation limited to a specific oral health problem or complaint, as defined by the CDT.

N. Oral Cavity means the jaw, mouth or any structure contiguous to the jaw.

O. Palliative Treatment for Dental Pain means emergency treatment to relieve the client of pain; it is not a mechanism for addressing chronic pain.

P. Periodic Oral Evaluation means an evaluation performed on a client of record to determine any changes in the patient's dental and medical status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation and periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures, as defined by the CDT.

Q. Periodontal Treatment means the therapeutic plan intended to stop or slow periodontal (gum) disease progression.

R. Preventive services means services concerned with promoting good oral health and function by preventing or reducing the onset and/or development of oral diseases or deformities and the occurrence of oro-facial injuries, as defined by the CDT.

S. Prophylaxis (Cleaning) is the removal of dental plaque and calculus from teeth, in order to prevent dental caries, gingivitis and periodontitis.

T. Re-Evaluation - Limited, Problem Focused (Established Patient; Not Post-Operative Visit) means assessing the status of a previously existing condition. For example, a traumatic injury where no treatment was rendered but patient needs follow-up monitoring, an evaluation for undiagnosed continuing pain, or a soft tissue lesion requiring follow-up evaluation, as defined by the CDT.

U. Restorative means services rendered for the purpose of rehabilitation of dentition to functional or aesthetic requirements of the client, as defined by the CDT.

V. Year begins on the date of service.

8.201.2BENEFITS

8.201.2.A Covered Services

1. Covered Evaluation Procedures:

a. Periodic Oral Evaluation,

i. Shall be limited to two (2) per year.

ii. Is limited to any combination of two (2) periodic oral evaluations, comprehensive oral evaluations, or comprehensive periodontal oral evaluations per year.

iii. Must be rendered by a dental professional.

b. Limited Oral Evaluation- Problem Focused; available to Adult Clients presenting with a specific oral health condition or problem

i. Shall be limited to two (2) per year per provider or location.

ii. Is limited to any combination of two (2) limited problem-focused oral evaluations, detailed and extensive problem-focused oral evaluations, or re-evaluation of limited and problem-focused oral evaluations per year per provider or location.

iii. Does not count towards other oral evaluation frequencies.

iv. Must be rendered by a dental professional. Dental hygienists shall only provide limited oral evaluations for an Adult Client of record.

v. Limited Oral Evaluation- Problem Focused will not be reimbursed if it is provided on the same day as a periodic oral evaluation, a comprehensive oral evaluation, or a comprehensive periodontal evaluation. When both are provided on the same day, only the periodic oral evaluation, the comprehensive oral evaluation, or the comprehensive periodontal evaluation will be reimbursed.

c. Comprehensive Oral Evaluation, New or Established Patient

i. Shall be limited to one (1) every three (3) years per provider or location.

ii. Is limited to any combination of two (2) periodic oral evaluations, comprehensive oral evaluations, or comprehensive periodontal oral evaluations per year.

iii. Must be rendered by a dentist only.

d. Detailed and Extensive Oral Evaluation- Problem Focused, By Report

i. Shall be limited to two (2) per year per provider or location.

iii. Does not count towards other oral evaluation frequencies.

iv. Must be rendered by a dental professional.

v. Will not be reimbursed if it is provided on the same day as a periodic oral evaluation, a comprehensive oral evaluation, or a comprehensive periodontal evaluation. When both are provided on the same day, only the periodic oral evaluation, the comprehensive oral evaluation, or the comprehensive periodontal evaluation will be reimbursed.

e. Re-evaluation- Limited, Problem Focused (Established Patient; Not PostOperative Visit)

i. Shall be limited to two (2) per year per provider or location.

iii. Does not count towards other oral evaluation frequencies.

iv. Must be rendered by a dental professional.

f. Comprehensive Periodontal Oral Evaluation

i. Shall be limited to one (1) every three (3) years.

ii. Is limited to any combination of two (2) periodic oral evaluations, comprehensive oral evaluations, or comprehensive periodontal oral evaluations per year.

iii. Must be rendered by a dental professional.

2. Covered Diagnostic Imaging Procedures:

a. Intra-oral - Complete Series of Radiographic Images, shall be limited to one (1) per five (5) years; minimum of ten (10) (periapical or posterior bitewing) images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone required in the radiographic survey counts as one (1) set of bitewings per year.

b. Intra-oral - Periapical First Radiographic Image, shall be limited to six (6) per one (1) year. Intra-oral first periapical x-ray will not be reimbursed if it is provided on the same day as an intra-oral- complete series. Where both are provided on the same day, only the intra-oral- complete series will be reimbursed.

c. Intra-oral - Periapical Each Additional Radiographic Image. Each additional periapical x-ray will not be reimbursed if it is provided on the same day as an intra-oral- complete series. Where both are provided on the same day, only the intra-oral- complete series will be reimbursed. Working and final treatment films for endodontics are not covered.

d. Bitewing - Single Radiographic Image, shall be limited to one (1) set per year; one (1) set is equal to one (1) to four (4) films.

e. Bitewing - Two Radiographic Images, shall be limited to one (1) set per year; one (1) set is equal to two (2) to four (4) films.

f. Bitewing - Three Radiographic Images, shall be limited to one (1) set per year; one (1) set is equal to two (2) to four (4) films.

g. Bitewing - Four Radiographic Images, shall be limited to one (1) set per year; one (1) set is equal to two (2) to four (4) films.

h. Vertical Bitewings - Seven (7) to Eight (8) Radiographic Images, shall be limited to one (1) every five (5) years per provider or location. Counts as an intra-oral-complete series.

i. Panoramic Radiographic Image; with or without bitewing, shall be limited to one (1) per five (5) years per provider or location. Counts as an intra-oral- complete series.

3. Covered Preventive Services

a. Prophylaxis (cleaning) shall be limited to two (2) per year. Tooth brushing alone does not qualify as a prophylaxis.

i. Adult Clients who indicate as high risk of periodontal disease or high risk of caries may receive any combination of up to a total of four (4) prophylaxes (cleanings) or four (4) periodontal maintenance visits per year. Indicators of high risk of periodontal disease include:

1. Demonstrable caries at the time of examination;

2. History of periodontal scaling and root planing;

3. History of periodontal surgery;

4. Diabetic diagnosis; or

5. Pregnancy.

b. Topical Application of Fluoride Varnish, shall be limited to two (2) per year, limited to Adult Clients with:

i. History of dry mouth; or

ii. History of head or neck radiation; or

iii. Indication of high risk for caries as that term is defined at Section 8.201.1. If, at the end of the year the Adult Client no longer has demonstrable caries, he or she is no longer considered high risk.

Limited to any combination of two (2) topical application of fluoride varnish or topical application of fluoride per year.

c. Topical Application of Fluoride, shall be limited to two (2) per year, limited to Adult Clients with:

i. History of dry mouth; or

ii. History of head or neck radiation; or

iv. Limited to any combination of two (2) fluoride varnish or topical fluoride applications per year.

4. Covered Minor Restorative Services.

a. Routine amalgam and composite fillings on posterior and anterior teeth are covered services.

b. Amalgam and composite fillings shall be limited to one (1) time per surface per tooth, every three (3) years. The limitation shall begin on the date of service and multi-surface fillings are allowable. Amalgam and composite fillings will not be reimbursed if it is provided on the same day of treatment as a crown on the same tooth. Where both are provided on the same day, only the crown will be reimbursed.

c. The occlusal surface is exempt from the three (3) year frequency limitations listed under Section 8.201.2.A.4.b. when a multi-surface restoration is required or following endodontic therapy.

d. Prefabricated Stainless Steel Crown, Permanent Tooth; may be replaced once every three (3) years.

e. Prefabricated Stainless Steel Crown, with Resin Window; may be replaced once every three (3) years.

f. Protective Restoration, shall be limited to once per lifetime per tooth, primary and permanent teeth.

5. Covered Major Restorative Services

a. The following crowns are covered:

i. Single crowns, shall be limited to one (1) per tooth every seven (7) years.

ii. Core build-up, building shall be limited to one (1) per tooth every seven (7) years.

iii. Pre-fabricated post and core, shall be limited to one (1) per tooth every seven (7) years.

b. Crowns are covered services only when all of the following conditions are met:

i. The tooth is in occlusion; and

ii. The cause of the problem is either decay or fracture; and

iii. The tooth is not a third molar; and

iv. The tooth is not a second molar, unless crowning the second molar is necessary to support a partial denture or to maintain eight (8) artificial or natural posterior teeth in occlusion; and

v. The Adult Client's record reflects evidence of good and consistent oral hygiene; and One of the following is also true:

1. The tooth in question requires a multi-surface restoration and it cannot be restored with other restorative materials; or

2. A crown is requested by the dental professional for cracked tooth syndrome and the tooth is symptomatic and appropriate testing and documentation is provided.

c. Crown materials are limited to porcelain, full porcelain, noble metal, or high noble metal on anterior teeth and premolars.

6. Covered Endodontic Services

a. The following endodontic procedures are covered:

i. Pulpal debridement shall be limited to one (1) per tooth per lifetime, permanent teeth only.

1. Covered in emergency situations only.

2. Exempt from prior authorization process but may be subject to post-treatment and pre-payment review.

3. Will not be reimbursed when root canal is completed on the same day by the same dental provider or location.

ii. Root Canal, Anterior Tooth shall be limited to one (1) per tooth per lifetime, permanent teeth only.

iii. Root Canal, Bicuspid Tooth shall be limited to one (1) per tooth per lifetime, permanent teeth only.

iv. Root canal, Molar Tooth shall be limited to one (1) per tooth per lifetime, permanent teeth only.

v. Retreatment of Previous Root Canal Therapy, Anterior Tooth shall be limited to one (1) per lifetime; permanent teeth only. Will not be reimbursed if the original treatment was previously reimbursed to the same dental provider or location by Colorado Medicaid. Requires prior authorization.

vi. Retreatment of Previous Root Canal Therapy, Bicuspid Tooth shall be limited to one (1) per lifetime; permanent teeth only. Will not be reimbursed if the original treatment was previously reimbursed to the same dental provider or location by Colorado Medicaid. Requires prior authorization.

vii. Retreatment of Previous Root Canal Therapy, Molar Tooth shall be limited to one (1) per lifetime; permanent teeth only. Will not be reimbursed if the original treatment was previously reimbursed to the same dental provider or location by Colorado Medicaid. Requires prior authorization.

b. Endodontic procedures are covered services when:

i. The tooth is not a third molar; and

ii. The tooth is not a second molar; root canal treatment on second molars is covered only when the second molar is necessary to support a partial denture or to maintain eight (8) artificial or natural posterior teeth in occlusion; and

iii. The Adult Client's record reflects evidence of good and consistent oral hygiene; and

1. The cause of the problem is either decay or fracture; and one of the following is also true:

a. The tooth is in occlusion; or

b. A root canal is requested by the dental professional for cracked tooth syndrome and the tooth is symptomatic and appropriate testing and documentation is provided.

c. In all instances in which the Adult Client is in acute pain or there exist acute trauma, the dentist should take the necessary steps to relieve the pain and complete the Emergency Services. In these instances, there may not be time for prior authorization. Such emergency services shall be subject to post-treatment and pre-payment review.

d. Working films (including the final treatment film) for endodontic procedures are considered part of the procedure and will not be paid for separately.

7. Covered Periodontal Treatment

a. Gingivectomy or Gingivoplasty, Four or More Contiguous Teeth or Tooth Bounded Spaces per Quadrant shall be limited to one (1) per three (3) years per Adult Client per quadrant. Includes six (6) months of postoperative care.

b. Gingivectomy or gingivoplasty, One to Three Contiguous Teeth or Tooth Bounded Spaces per Quadrant shall be limited to one (1) per three (3) years per Adult Client per quadrant. Includes six (6) months of postoperative care.

c. Gingivectomy or Gingivoplasty to Allow Access for Restorative Procedure, per Tooth shall be limited to one (1) per three (3) years per Adult Client per quadrant.

d. Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis; shall be limited to one (1) per three (3) years per Adult Client.

i. Full mouth debridement will not be reimbursed if Adult Client's patient record demonstrates that the Adult Client has had a prophylaxis (cleaning) or periodontal maintenance in the previous twelve (12) month period.

ii. Other periodontal treatments will not be reimbursed when provided on the same date as full mouth debridement. Where other periodontal services are provided on the same day, only the full mouth debridement will be reimbursed.

iii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as full mouth debridement. Where both are provided on the same day, only the full mouth debridement will be reimbursed.

e. Periodontal Scaling and Root Planing, Four (4) or More Teeth per Quadrant shall be limited to one (1) per quadrant every three (3) years. Requires prior authorization.

i. Only covered by report. Periodontal disease must be documented in the patient record.

ii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as a periodontal scaling and root planing, four (4) or more teeth per quadrant. Where both are provided on the same day, only the periodontal scaling and root planing, four (4) or more teeth per quadrant will be reimbursed.

iii. No more than two (2) quadrants per day.

f. Periodontal Scaling and Root Planing, One (1) to Three (3) Teeth per Quadrant shall be limited to one (1) per quadrant every three (3) years. Requires prior authorization.

i. Only covered by report. Periodontal disease must be documented in the patient record.

ii. Prophylaxis (cleaning) will not be reimbursed if it is provided on the same day as a periodontal scaling and root planing, one (1) to three (3) teeth per quadrant. Where both are provided on the same day, only the periodontal scaling and root planing, one (1) to three (3) teeth per quadrant will be reimbursed.

iii. No more than two (2) quadrants per day.

g. Periodontal Maintenance, shall be limited to two (2) times per year; counts as a prophylaxis (cleaning).

1. Demonstrable caries at the time of examination;

2. History of periodontal scaling and root planing;

3. History of periodontal surgery;

4. Diabetic diagnosis; or

5. Pregnancy.

h. In all instances in which the Adult Client is in acute pain or there exist acute trauma, the dentist should take the necessary steps to relieve the pain and complete the Emergency Services. In these instances, there may not be time for prior authorization. Such emergency services shall be subject to post-treatment and pre-payment review.

8. Covered Removable Prosthetics

a. Removable prosthetics are not covered if eight (8) or more posterior teeth (natural or artificial) are in occlusion. Anterior teeth shall be covered, irrespective of the number of teeth in occlusion.

b. Removable prosthetics covered include:

i. Complete Upper Dentures shall be limited to one (1) time every seven (7) years. Includes initial six (6) months of relines. Requires prior authorization.

ii. Complete Lower Dentures shall be limited to one (1) time every seven (7) years. Includes initial six (6) months of relines. Requires prior authorization.

iii. Removable Partial Upper Denture, Resin Based shall be limited to one (1) time every seven (7) years. Requires prior authorization.

iv. Removable Partial Lower Denture, Resin Based shall be limited to one (1) time every seven (7) years. Requires prior authorization.

v. Removable Partial Upper Denture, Cast Metal Framework shall be limited to one (1) time seven (7) years. Requires prior authorization.

vi. Removable Partial Lower Denture, Cast Metal Framework shall be limited to one (1) time every seven (7) years. Requires prior authorization.

vii. Removable Partial Upper Denture, Flexible Base shall be limited to one (1) time every seven (7) years. Requires prior authorization.

viii. Removable Partial Lower Denture, Flexible Base shall be limited to one (1) time every seven (7) years. Requires prior authorization.

9. Covered Oral Surgery, Palliative Treatment and Anesthesia

a. The following surgical and palliative treatments are covered:

i. Simple Extraction shall be limited to one (1) time per tooth.

ii. Surgical Extraction shall be limited to one (1) time per tooth.

iii. Incision and Drainage of Abscess, concurrent with extraction will be covered by report when narrative of medical necessity can be documented. Will not be reimbursed in same surgical area and on same visit as any other definitive treatment codes, except for covered services necessary for diagnosis. Such incision and drainage procedures may be subject to post-treatment and pre-payment review.

iv. Minor surgical procedures to prepare the mouth for removable prostheses shall be limited to one (1) time per lifetime per quadrant.

v. Palliative Treatment of Dental Pain will not be reimbursed on same visit as any definitive treatment codes; except for radiographs necessary for diagnosis. Will not be reimbursed when only other service is writing a prescription.

vi. Deep Sedation/General Anesthesia.

1. Only covered for Adult Clients when there is sufficient evidence to support medical necessity.

2. Where multiple levels of anesthesia are provided on the same day, only the highest level of anesthesia administered will be reimbursed.

vii. Intravenous Conscious Sedation.

1. Only covered for Adult Clients when there is sufficient evidence to support medical necessity.

2. Where multiple levels of anesthesia are provided on the same day, only the highest level of anesthesia administered will be reimbursed.

b. In all instances in which the Adult Client is in acute pain or there exist acute trauma, the dentist should take the necessary steps to relieve the pain and complete the Emergency Services. In these instances, there may not be time for prior authorization. Such emergency services shall be subject to post-treatment and pre-payment review.

c. Biopsies are covered only in instances where there is a suspicious lesion.

d. Removal of third molars is only covered in instances of acute pain and overt symptomatology.

10. Covered Hospital-Based Services

a. Dental treatment is covered in a hospital or outpatient facility, under deep sedation or general anesthesia, only when there is medical necessity.

b. Under this Section 10, medical necessity shall be limited to the following:

i. Patients with a documented physical, mental or medically compromising condition.

ii. Patients who have a dental need and for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy.

iii. Patients who are extremely uncooperative, unmanageable, anxious or uncommunicative and who have dental needs deemed sufficiently urgent that care cannot be deferred. Evidence of the attempt to manage in an outpatient setting must be provided; or

iv. Patients who have sustained extensive orofacial and dental trauma.

c. All operating room cases require prior authorization, even if the complete treatment plan is not available.

d. General anesthesia and sedation are not covered services when the patient is cooperative and requires minimal dental treatment, or when the patient has a concomitant medical condition which would make general anesthesia or sedation unsafe.

8.201.2.B. Exclusions.

1. The following services/treatments are not a benefit for Adult Clients age 21 years and older under any circumstances:

a. Cosmetic Procedures.

b. Crowns in the following categories:

i. Cosmetic Crowns (i.e., crowns solely for cosmetic purposes);

ii. Multiple units of crown and bridge;

iii. To restore vertical dimension;

iv. When an Adult Client has active and advanced periodontal disease;

v. When the tooth is not in occlusion; or

vi. When there is evidence of periapical pathology.

c. Implants.

d. Screening and assessment.

e. Periodontal surgery.

f. Graft procedures.

g. Endodontic surgery.

h. Treatment for temporomandibular joint disorders.

i. Orthodontic treatment.

j. Tobacco cessation counseling.

k. Oral hygiene instruction.

l. Any service that is not listed as covered.

8.201.3PRIOR AUTHORIZATION REQUEST

1. Emergency Services do not require a prior authorization before services can be rendered, and shall be subject to pre-payment review.

2. Prior authorizations or benefits shall be denied for reasons of poor dental prognosis, lack of dental necessity or appropriateness or because the requested services do not meet the generally accepted standard of dental care.

3. The following services require prior authorization:

a. Complete and partial dentures.

b. Scaling and root planing (periodontal maintenance).

c. Retreatment of root canals.

d. Hospital-based services when treatment is required.

e. Unspecified procedures, by report.

8.201.4PROVIDER REQUIREMENTS/REIMBURSEMENT

8.201.4.A. Dental services shall only be provided by a licensed dental professional who is enrolled with Colorado Medicaid. Providers shall only provide covered services that are within the scope of their practice.

8.201.4.B. The following billing limitations apply:

1. Restorations:

a. Tooth preparation, anesthesia, all adhesives, liners and bases, polishing and occlusal adjustments shall be included within the reimbursement rate for restoration. Unbundling of dental restorations for billing purposes is not allowed.

b. Amalgam and composite restorations shall be reimbursed at the same rate.

c. Claim payment to a dental provider for one (1) or more restorations for the same tooth shall be limited to a total of four (4) or more tooth surfaces.

8.201.5ELIGIBLE CLIENTS

Dental services described in 8.201.2 shall apply to Adult Clients age 21 years and older.

8.201.6ANNUAL LIMITS

1. Beginning July 1, 2019, dental services for Adult Clients age 21 years and older shall be limited to a total of $1,500 per Medicaid Adult Client per state fiscal year. An Adult Client may make personal expenditures for any dental services that exceed the $1,500 annual limit.

2. The complete and partial dentures benefit shall be subject to prior authorization and shall not be subject to the annual maximum for dental services for Adult Clients age 21 years and older. Although the complete and partial dentures benefit is not subject to the annual maximum for the adult dental services, it shall be subject to a set Medicaid allowable rate.

10 CCR 2505-10-8.201

46 CR 11, June 10, 2023, effective 5/12/2023

46 CR 17, September 10, 2023, effective 8/11/2023, exp. 12/9/2023 (EMERGENCY)

46 CR 17, September 10, 2023, effective 9/30/2023