Statutes, codes, and regulations
Washington Administrative Code
Title 182 - Health Care AuthorityWASHINGTON APPLE HEALTH
Chapter 182-535A - Orthodontic services
Section 182-535A-0040 - Orthodontic treatment and orthodontic-related services-Covered, noncovered, and limitations to coverage

Wash. Admin. Code § 182-535A-0040

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Current through Register Vol. 24-23, December 1, 2024
Section 182-535A-0040 - Orthodontic treatment and orthodontic-related services-Covered, noncovered, and limitations to coverage

Orthodontic treatment and orthodontic-related services require prior authorization.

(1) The medicaid agency covers orthodontic treatment and orthodontic-related services for a client who has one of the medical conditions listed in (a) and (b) of this subsection. Treatment and follow-up care must be performed by a provider who is part of a craniofacial team that includes, but is not limited to, a general or pediatric dentist, orthodontist, and an oral maxillofacial surgeon or specialist.
(a) Cleft lip and palate, cleft palate, or cleft lip.
(b) The following craniofacial anomalies including, but not limited to:
(i) Hemifacial microsomia;
(ii) Craniosynostosis syndromes;
(iii) Cleidocranial dental dysplasia;
(iv) Arthrogryposis;
(v) Marfan syndrome;
(vi) Treacher Collins syndrome;
(vii) Ectodermal dysplasia; or
(viii) Achondroplasia.
(2) The agency authorizes orthodontic treatment and orthodontic-related services when the following criteria are met:
(a) Severe malocclusions with a Washington Modified Handicapping Labiolingual Deviation (HLD) Index Score of 25 or higher as determined by the agency;
(b) The client has established caries control; and
(c) The client has established plaque control.
(3) The agency covers orthodontic treatment for dental malocclu-sions other than those listed in subsections (1) and (2) of this section on a case-by-case basis when the agency determines medical necessity based on documentation submitted by the provider.
(4) The agency does not cover the following orthodontic treatment or orthodontic-related services:
(a) Orthodontic treatment for cosmetic purposes;
(b) Orthodontic treatment that is not medically necessary;
(c) Orthodontic treatment provided out-of-state, except as stated in WAC 182-501-0180 (see also WAC 182-501-0175 for medical care provided in bordering cities); or
(d) Orthodontic treatment and orthodontic-related services that do not meet the requirements of this section or other applicable WAC.
(5) The agency covers the following orthodontic treatment and orthodontic-related services:
(a) Limited orthodontic treatment.
(b) Comprehensive full orthodontic treatment on adolescent dentition.
(c) A case study when done in conjunction with orthodontic treatment.
(d) Other orthodontic treatment subject to review for medical necessity as determined by the agency.
(6) The agency covers the following orthodontic-related services:
(a) Clinical oral evaluations according to WAC 182-535-1080.
(b) Cephalometric films that are of diagnostic quality, dated, and labeled with the client's name.
(c) Orthodontic appliance removal as a stand-alone service only when:
(i) The client's appliance was placed by a different provider or dental clinic; and
(ii) The provider has not furnished any other orthodontic treatment or orthodontic-related services to the client.
(7) The treatment must meet industry standards and correct the medical issue. If treatment is discontinued prior to completion, or treatment objectives are not achieved, the provider must:
(a) Document in the client's record why treatment was discontinued or not completed, or why treatment goals were not achieved.
(b) Notify the agency by submitting the Orthodontic Discontinuation of Service form (HCA 13-0039).
(8) The agency evaluates a request for orthodontic treatment or orthodontic-related services:
(a) That are in excess of the limitations or restrictions listed in this section, according to WAC 182-501-0169; and
(b) That are listed as noncovered according to WAC 182-501-0160.
(9) The agency reviews requests for orthodontic treatment or orthodontic-related services for clients who are eligible for services under the EPSDT program according to the provisions of WAC 182-534-0100.

Wash. Admin. Code § 182-535A-0040

Amended by WSR 14-08-032, filed 3/25/14, effective 4/30/2014
Amended by WSR 16-10-064, Filed 5/2/2016, effective 6/2/2016
Amended by WSR 17-20-097, Filed 10/3/2017, effective 11/3/2017
Amended by WSR 19-11-028, Filed 5/7/2019, effective 7/1/2019
Amended by WSR 20-03-042, Filed 1/8/2020, effective 2/8/2020
Amended by WSR 21-18-006, Filed 8/18/2021, effective 1/1/2022
Amended by WSR 23-08-009, Filed 3/23/2023, effective 4/23/2023
Amended by WSR 23-24-099, Filed 12/6/2023, effective 1/6/2024

11-14-075, recodified as §182-535A-0040, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. 08-17-009, § 388-535A-0040, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-535A-0040, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. 05-01-064, § 388-535A-0040, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396 d(a), C.F.R. 440.100 and 225. 02-01-050, § 388-535A-0040, filed 12/11/01, effective 1/11/02.