Section 182-535-1084 - Dental-related services-Covered-Restorative servicesClients described in WAC 182535-1060 are eligible for the dental-related restorative services listed in this section, subject to coverage limitations, restrictions, and client age requirements identified for a specific service.
(1)Amalgam, resin, and glass ionomer restorations for primary and permanent teeth. The medicaid agency considers:(a) Tooth preparation, acid etching, all adhesives (including bonding agents), liners and bases, indirect and direct pulp capping, polishing, and curing as part of the restoration.(b) Occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of the restoration.(c) Restorations placed within six months of a crown preparation by the same provider or clinic to be included in the payment for the crown.(2)Limitations for all restorations. The agency:(a) Considers multiple restoration involving the proximal and occlusal surfaces of the same tooth as a multisurface restoration, and limits reimbursement to a single multisurface restoration.(b) Considers multiple restorative resins, flowable composite resins, resin-based composites, or glass ionomer restorations for the occlusal, buccal, lingual, mesial, and distal fissures and grooves on the same tooth as a one-surface restoration.(c) Considers multiple restorations of fissures and grooves of the occlusal surface of the same tooth as a one-surface restoration.(d) Considers resin-based composite restorations of teeth where the decay does not penetrate the dentinoenamel junction (DEJ) to be sealants. (See WAC 182-535-1082 for sealant coverage.)(e) Covers only one buccal and one lingual surface per tooth. The agency reimburses buccal or lingual restorations, regardless of size or extension, as a one-surface restoration. (f) Does not cover preventative restorations.(g) Covers replacement restorations between six and twenty-four months of original placement, with approved prior authorization, if the restoration is cracked or broken. The client's record must include X-rays or documentation supporting the medical necessity for the replacement restoration.(h) Replacement of a cracked or broken restoration within a six-month period by the same provider is considered part of the global payment of the initial restoration and will not pay separately.(3)Additional limitations for restorations on permanent teeth. The agency covers:(a) Two occlusal restorations for the upper molars on teeth one, two, three, fourteen, fifteen, and sixteen if, the restorations are anatomically separated by sound tooth structure.(b) A maximum of five surfaces per tooth for permanent posterior teeth, except for upper molars. The agency allows a maximum of six surfaces per tooth for teeth one, two, three, fourteen, fifteen, and sixteen.(c) A maximum of six surfaces per tooth for resin-based composite restorations for permanent anterior teeth.(4)Crowns. The agency: (a) Covers the following indirect crowns once every five years, per tooth, for permanent anterior teeth for clients age fifteen through twenty when the crowns meet prior authorization criteria in WAC 182-535-1220 and the provider follows the prior authorization requirements in (c) of this subsection:(i) Porcelain/ceramic crowns to include all porcelains, glasses, glass-ceramic, and porcelain fused to metal crowns; and(ii) Resin crowns and resin metal crowns to include any resin-based composite, fiber, or ceramic reinforced polymer compound.(b) Considers the following to be included in the payment for a crown:(i) Tooth and soft tissue preparation;(ii) Amalgam and resin-based composite restoration, or any other restorative material placed within six months of the crown preparation. Exception: The agency covers a one-surface restoration on an endodontically treated tooth, or a core buildup or cast post and core;(iii) Temporaries including, but not limited to, temporary restoration, temporary crown, provisional crown, temporary prefabricated stainless steel crown, ion crown, or acrylic crown;(iv) Packing cord placement and removal;(v) Diagnostic or final impressions;(vi) Crown seating (placement), including cementing and insulating bases;(vii) Occlusal adjustment of crown or opposing tooth or teeth; and(c) Requires the provider to submit the following with each prior authorization request:(i) Radiographs to assess all remaining teeth;(ii) Documentation and identification of all missing teeth;(iii) Caries diagnosis and treatment plan for all remaining teeth, including a caries control plan for clients with rampant caries;(iv) Pre- and post-endodontic treatment radiographs for requests on endodontically treated teeth; and(v) Documentation supporting a five-year prognosis that the client will retain the tooth or crown if the tooth is crowned.(d) Requires a provider to bill for a crown only after delivery and seating of the crown, not at the impression date.(5)Other restorative services. The agency covers the following restorative services:(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 three years only for clients age twenty and younger. (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 three years without prior authorization for clients ages zero through twelve and with prior authorization for clients age thirteen through twenty if: (i) The tooth had a pulpotomy; or(ii) Evidence of Class II caries with rampant decay; or(iii) Evidence of extensive caries; or(iv) Treatment of decay requires sedation or general anesthesia.(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 three years, for clients age twenty and younger, without prior authorization.(e) Prefabricated stainless steel crowns, for permanent posterior teeth, excluding one, sixteen, seventeen, and thirty-two for clients age twenty-one and older in lieu of a restoration requiring three or more surfaces.(f) Prefabricated stainless steel crowns for clients of the developmental disabilities administration of the department of social and health services (DSHS) without prior authorization in accordance with WAC 182-535-1099. (g) Core buildup, including pins, only on permanent teeth, only for clients age twenty and younger, and only allowed in conjunction with crowns and when prior authorized. For indirect crowns, prior authorization must be obtained from the agency at the same time as the crown. Providers must submit pre- and post-endodontic treatment radiographs to the agency with the authorization request for end-odontically treated teeth.(h) Cast post and core or prefabricated post and core, only on permanent teeth, only for clients age twenty and younger, and only when in conjunction with a crown and when prior authorized.Wash. Admin. Code § 182-535-1084
Amended by WSR 14-08-032, filed 3/25/14, effective 4/30/2014Amended by WSR 15-10-043, Filed 4/29/2015, effective 5/30/2015Amended by WSR 16-18-033, Filed 8/26/2016, effective 9/26/2016Amended by WSR 17-20-097, Filed 10/3/2017, effective 11/3/2017Amended by WSR 18-12-033, Filed 5/29/2018, effective 7/1/2018Amended by WSR 19-09-058, Filed 4/15/2019, effective 7/1/2019Amended by WSR 21-14-055, Filed 7/1/2021, effective 8/1/2021Statutory Authority: RCW 41.05.021. 12-09-081, §182-535-1084, filed 4/17/12, effective 5/18/12. 11-14-075, recodified as §182-535-1084, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1084, filed 3/1/07, effective 4/1/07.