WAC 388-535-1084   Covered dental-related services for clients through age twenty -- Restorative services.  The department covers medically necessary dental-related restorative services, subject to the coverage limitations listed, for clients through age twenty as follows:

     (1) Restorative/operative procedures. The department covers restorative/operative procedures performed in a hospital or an ambulatory surgical center for:

     (a) Clients ages eight and younger;

     (b) Clients ages nine through twenty only on a case-by-case basis and when prior authorized; and

     (c) Clients of the division of developmental disabilities according to WAC 388-535-1099.

     (2) Amalgam restorations for primary and permanent teeth. The department considers:

     (a) Tooth preparation, all adhesives (including amalgam bonding agents), liners, bases, and polishing as part of the amalgam restoration.

     (b) The occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of the amalgam restoration.

     (c) Buccal or lingual surface amalgam restorations, regardless of size or extension, as a one surface restoration. The department covers one buccal and one lingual surface per tooth.

     (d) Multiple amalgam restorations of fissures and grooves of the occlusal surface of the same tooth as a one surface restoration.

     (e) Amalgam restorations placed within six months of a crown preparation by the same provider or clinic to be included in the payment for the crown.

     (3) Amalgam restorations for primary posterior teeth only. The department covers amalgam restorations for a maximum of two surfaces for a primary first molar and maximum of three surfaces for a primary second molar. (See subsection (9)(c) of this section for restorations for a primary posterior tooth requiring additional surfaces.) The department does not pay for additional amalgam restorations.

     (4) Amalgam restorations for permanent posterior teeth only. The department:

     (a) Covers two occlusal amalgam restorations for teeth one, two, three fourteen, fifteen, and sixteen, if the restorations are anatomically separated by sound tooth structure.

     (b) Covers amalgam restorations for a maximum of five surfaces per tooth for a permanent posterior tooth, once per client, per provider or clinic, in a two-year period.

     (c) Covers amalgam restorations for a maximum of six surfaces per tooth for teeth one, two, three, fourteen, fifteen, and sixteen, once per client, per provider or clinic, in a two-year period (see (a) of this subsection).

     (d) Does not pay for replacement of amalgam restoration on permanent posterior teeth within a two-year period unless the restoration has an additional adjoining carious surface. The department pays for the replacement restoration as one multi-surface restoration. The client's record must include radiographs and documentation supporting the medical necessity for the replacement restoration.

     (5) Resin-based composite restorations for primary and permanent teeth. The department:

     (a) Considers tooth preparation, acid etching, all adhesives (including resin bonding agents), liners and bases, polishing, and curing as part of the resin-based composite restoration.

     (b) Considers the occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of the resin-based composite restoration.

     (c) Considers buccal or lingual surface resin-based composite restorations, regardless of size or extension, as a one surface restoration. The department covers only one buccal and one lingual surface per tooth.

     (d) Considers resin-based composite restorations of teeth where the decay does not penetrate the DEJ to be sealants (see WAC 388-535-1082(4) for sealants coverage).

     (e) Considers multiple preventive restorative resin, flowable composite resin, or resin-based composites for the occlusal, buccal, lingual, mesial, and distal fissures and grooves on the same tooth as a one surface restoration.

     (f) Does not cover preventive restorative resin or flowable composite resin on the interproximal surfaces (mesial and/or distal) when performed on posterior teeth or the incisal surface of anterior teeth.

     (g) Considers resin-based composite restorations placed within six months of a crown preparation by the same provider or clinic to be included in the payment for the crown.

     (6) Resin-based composite restorations for primary teeth only. The department covers:

     (a) Resin-based composite restorations for a maximum of three surfaces for a primary anterior tooth (see subsection (9)(b) of this section for restorations for a primary anterior tooth requiring a four or more surface restoration). The department does not pay for additional composite or amalgam restorations on the same tooth after three surfaces.

     (b) Resin-based composite restorations for a maximum of two surfaces for a primary first molar and a maximum of three surfaces for a primary second molar. (See subsection (9)(c) of this subsection for restorations for a primary posterior tooth requiring additional surfaces.) The department does not pay for additional composite restorations on the same tooth.

     (c) Glass ionimer restorations only for primary teeth, and only for clients ages five and younger. The department pays for these restorations as a one surface resin-based composite restoration.

     (7) Resin-based composite restorations for permanent teeth only. The department covers:

     (a) Two occlusal resin-based composite restorations for teeth one, two, fourteen, fifteen, and sixteen if the restorations are anatomically separated by sound tooth structure.

     (b) Resin-based composite restorations for a maximum of five surfaces per tooth for a permanent posterior tooth, once per client, per provider or clinic, in a two-year period.

     (c) Resin-based composite restorations for a maximum of six surfaces per tooth for permanent posterior teeth one, two, three, fourteen, fifteen, and sixteen, once per client, per provider or clinic, in a two-year period (see (a) of this subsection).

     (d) Resin-based composite restorations for a maximum of six surfaces per tooth for a permanent anterior tooth, once per client, per provider or clinic, in a two-year period.

     (e) Replacement of resin-based composite restoration on permanent teeth within a two-year period only if the restoration has an additional adjoining carious surface. The department pays the replacement restoration as a one multi-surface restoration. The client's record must include radiographs and documentation supporting the medical necessity for the replacement restoration.

     (8) Crowns. The department:

     (a) Covers the following crowns once every five years, per tooth, for permanent anterior teeth for clients ages twelve through twenty when the crowns meet prior authorization criteria in WAC 388-535-1220 and the provider follows the prior authorization requirements in (d) 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) Covers full coverage metal crowns once every five years, per tooth, for permanent posterior teeth to include high noble, titanium, titanium alloys, noble, and predominantly base metal crowns for clients ages eighteen through twenty when they meet prior authorization criteria and the provider follows the prior authorization requirements in (d) and (e) of this subsection.

     (c) 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 department 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, including cementing and insulating bases;

     (vii) Occlusal adjustment of crown or opposing tooth or teeth; and

     (viii) Local anesthesia.

     (d) 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.

     (e) Requires a provider to bill for a crown only after delivery and seating of the crown, not at the impression date.

     (9) Other restorative services. The department covers:

     (a) All recementations of permanent indirect crowns.

     (b) Prefabricated stainless steel crowns with resin window, resin-based composite crowns, prefabricated esthetic coated stainless steel crowns, and fabricated resin crowns for primary anterior teeth once every three years without prior authorization if the tooth requires a four or more surface restoration.

     (c) Prefabricated stainless steel crowns for primary posterior teeth once every three years without prior authorization if:

     (i) Decay involves three or more surfaces for a primary first molar;

     (ii) Decay involves four or more surfaces for a primary second molar; or

     (iii) The tooth had a pulpotomy.

     (d) Prefabricated stainless steel crowns for permanent posterior teeth once every three years when prior authorized.

     (e) Prefabricated stainless steel crowns for clients of the division of developmental disabilities according to WAC 388-535-1099.

     (f) Core buildup, including pins, only on permanent teeth, when prior authorized at the same time as the crown prior authorization.

     (g) Cast post and core or prefabricated post and core, only on permanent teeth, when prior authorized at the same time as the crown prior authorization.



[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.]