WAC 388-535-1080   Covered dental-related services for clients through age twenty--Diagnostic.  The department covers medically necessary dental-related diagnostic services, subject to the coverage limitations listed, for clients through age twenty as follows:

     (1) Clinical oral evaluations. The department covers:

     (a) Oral health evaluations and assessments.

     (b) Periodic oral evaluations as defined in WAC 388-535-1050, once every six months. Six months must elapse between the comprehensive oral evaluation and the first periodic oral evaluation.

     (c) Limited oral evaluations as defined in WAC 388-535-1050, only when the provider performing the limited oral evaluation is not providing routine scheduled dental services for the client. The limited oral evaluation:

     (i) Must be to evaluate the client for a:

     (A) Specific dental problem or oral health complaint;

     (B) Dental emergency; or

     (C) Referral for other treatment.

     (ii) When performed by a denturist, is limited to the initial examination appointment. The department does not cover any additional limited examination by a denturist for the same client until three months after a removable prosthesis has been seated.

     (d) Comprehensive oral evaluations as defined in WAC 388-535-1050, once per client, per provider or clinic, as an initial examination. The department covers an additional comprehensive oral evaluation if the client has not been treated by the same provider or clinic within the past five years.

     (e) Limited visual oral assessments as defined in WAC 388-535-1050, up to two per client, per year, per provider only when the assessment is:

     (i) Not performed in conjunction with other clinical oral evaluation services;

     (ii) Performed to determine the need for sealants or fluoride treatment and/or when triage services are provided in settings other than dental offices or clinics; and

     (iii) Provided by a licensed dentist or licensed dental hygienist.

     (2) Radiographs (X rays). The department:

     (a) Covers radiographs that are of diagnostic quality, dated, and labeled with the client's name. The department requires original radiographs to be retained by the provider as part of the client's dental record, and duplicate radiographs to be submitted with prior authorization requests, or when copies of dental records are requested.

     (b) Uses the prevailing standard of care to determine the need for dental radiographs.

     (c) Covers an intraoral complete series (includes four bitewings), once in a three-year period only if the department has not paid for a panoramic radiograph for the same client in the same three-year period.

     (d) Covers periapical radiographs that are not included in a complete series. Documentation supporting the medical necessity for these must be included in the client's record.

     (e) Covers an occlusal intraoral radiograph once in a two-year period. Documentation supporting the medical necessity for these must be included in the client's record.

     (f) Covers a maximum of four bitewing radiographs once every twelve months for clients through age eleven.

     (g) Covers a maximum of four bitewing radiographs once every twelve months for clients ages twelve through twenty.

     (h) Covers panoramic radiographs in conjunction with four bitewings, once in a three-year period, only if the department has not paid for an intraoral complete series for the same client in the same three-year period.

     (i) May cover panoramic radiographs for preoperative or postoperative surgery cases more than once in a three-year period, only on a case-by-case basis and when prior authorized.

     (j) Covers cephalometric film:

     (i) For orthodontics, as described in chapter 388-535A WAC; or

     (ii) Only on a case-by-case basis and when prior authorized.

     (k) Covers radiographs not listed as covered in this subsection, only on a case-by-case basis and when prior authorized.

     (l) Covers oral and facial photographic images, only on a case-by-case basis and when requested by the department.

     (3) Tests and examinations. The department covers:

     (a) One pulp vitality test per visit (not per tooth):

     (i) For diagnosis only during limited oral evaluations; and

     (ii) When radiographs and/or documented symptoms justify the medical necessity for the pulp vitality test.

     (b) Diagnostic casts other than those included in an orthodontic case study, on a case-by-case basis, and when requested by the department.



[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1080, filed 3/1/07, effective 4/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-078, § 388-535-1080, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1080, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1080, filed 3/10/99, effective 4/10/99.]