WAC 388-535-1082   Covered dental-related services for clients through age twenty -- Preventive services.  The department covers medically necessary dental-related preventive services, subject to the coverage limitations listed, for clients through age twenty as follows:

     (1) Dental prophylaxis. The department covers prophylaxis:

     (a) Which includes scaling and polishing procedures to remove coronal plaque, calculus, and stains when performed on primary, transitional, or permanent dentition, once every six months for clients through age twenty.

     (b) Only when the service is performed six months after periodontal scaling and root planing, or periodontal maintenance services, for clients ages thirteen through twenty.

     (c) Only when not performed on the same date of service as periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty.

     (d) For clients of the division of developmental disabilities according to WAC 388-535-1099.

     (2) Topical fluoride treatment. The department covers:

     (a) Fluoride varnish, rinse, foam or gel for clients ages six and younger, up to three times within a twelve-month period.

     (b) Fluoride varnish, rinse, foam or gel for clients ages seven through eighteen, up to two times within a twelve-month period.

     (c) Fluoride varnish, rinse, foam or gel, up to three times within a twelve-month period during orthodontic treatment.

     (d) Fluoride rinse, foam or gel for clients ages nineteen through twenty, once within a twelve-month period.

     (e) Additional topical fluoride applications only on a case-by-case basis and when prior authorized.

     (f) Topical fluoride treatment for clients of the division of developmental disabilities according to WAC 388-535-1099.

     (3) Oral hygiene instruction. The department covers:

     (a) Oral hygiene instruction only for clients through age eight.

     (b) Oral hygiene instruction up to two times within a twelve-month period.

     (c) Individualized oral hygiene instruction for home care to include tooth brushing technique, flossing, and use of oral hygiene aides.

     (d) Oral hygiene instruction only when not performed on the same date of service as prophylaxis.

     (e) Oral hygiene instruction only when provided by a licensed dentist or a licensed dental hygienist and the instruction is provided in a setting other than a dental office or clinic.

     (4) Sealants. The department covers:

     (a) Sealants only when used on a mechanically and/or chemically prepared enamel surface.

     (b) Sealants once per tooth in a three-year period for clients through age eighteen.

     (c) Sealants only when used on the occlusal surfaces of:

     (i) Permanent teeth two, three, fourteen, fifteen, eighteen, nineteen, thirty, and thirty-one; and

     (ii) Primary teeth A, B, I, J, K, L, S, and T.

     (d) Sealants on noncarious teeth or teeth with incipient caries.

     (e) Sealants only when placed on a tooth with no preexisting occlusal restoration, or any occlusal restoration placed on the same day.

     (f) Additional sealants on a case-by-case basis and when prior authorized.

     (5) Space maintenance. The department covers:

     (a) Fixed unilateral or fixed bilateral space maintainers for clients through age eighteen.

     (b) Only one space maintainer per quadrant.

     (c) Space maintainers only for missing primary molars A, B, I, J, K, L, S, and T.

     (d) Replacement space maintainers only on a case-by-case basis and when prior authorized.



[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1082, filed 3/1/07, effective 4/1/07.]