WAC 388-535-1099   Covered dental-related services for clients of the division of developmental disabilities.  The department pays for dental-related services under the categories of services listed in this section for clients of the division of developmental disabilities, subject to the coverage limitations listed. Chapter 388-535 WAC applies to clients of the division of developmental disabilities unless otherwise stated in this section.

     (1) Preventive services.

     (a) Dental prophylaxis. The department covers dental prophylaxis or periodontal maintenance up to three times in a twelve-month period (see subsection (3) of this section for limitations on periodontal scaling and root planing).

     (b) Topical fluoride treatment. The department covers topical fluoride varnish, rinse, foam or gel, up to three times within a twelve-month period.

     (c) Sealants. The department covers sealants:

     (i) Only when used on the occlusal surfaces of:

     (A) Primary teeth A, B, I, J, K, L, S, and T; or

     (B) Permanent teeth two, three, four, five, twelve, thirteen, fourteen, fifteen, eighteen, nineteen, twenty, twenty-one, twenty-eight, twenty-nine, thirty, and thirty-one.

     (ii) Once per tooth in a two-year period.

     (2) Crowns. The department covers stainless steel crowns every two years for the same tooth and only for primary molars and permanent premolars and molars, as follows:

     (a) For clients ages twenty and younger, the department does not require prior authorization for stainless steel crowns. Documentation supporting the medical necessity of the service must be in the client's record.

     (b) For clients ages twenty-one and older, the department requires prior authorization for stainless steel crowns.

     (3) Periodontic services.

     (a) Surgical periodontal services. The department covers:

     (i) Gingivectomy/gingivoplasty once every three years. Documentation supporting the medical necessity of the service must be in the client's record (e.g., drug induced gingival hyperplasia).

     (ii) Gingivectomy/gingivoplasty with periodontal scaling and root planing or periodontal maintenance when the services are performed:

     (A) In a hospital or ambulatory surgical center; or

     (B) For clients under conscious sedation, deep sedation, or general anesthesia.

     (b) Nonsurgical periodontal services. The department covers:

     (i) Periodontal scaling and root planing, up to two times per quadrant in a twelve-month period.

     (ii) Periodontal scaling (four quadrants) substitutes for an eligible periodontal maintenance or oral prophylaxis, twice in a twelve-month period.

     (4) Adjunctive general services.

     (a) Adjunctive general services. The department covers:

     (i) Oral parenteral conscious sedation, deep sedation, or general anesthesia for any dental services performed in a dental office or clinic. Documentation supporting the medical necessity must be in the client's record.

     (ii) Sedations services according to WAC 388-535-1098 (1)(c) and (e).

     (b) Nonemergency dental services. The department covers nonemergency dental services performed in a hospital or an ambulatory surgical center for services listed as covered in WAC 388-535-1082, 388-535-1084, 388-535-1086, 388-535-1088, and 388-535-1094. Documentation supporting the medical necessity of the service must be included in the client's record.

     (5) Miscellaneous services--Behavior management. The department covers behavior management provided in dental offices or dental clinics for clients of any age. Documentation supporting the medical necessity of the service must be included in the client's record.



[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1099, filed 3/1/07, effective 4/1/07.]