WAC 388-535-1100   Dental-related services not covered for clients through age twenty.  (1) The department does not cover the following for clients through age twenty:

     (a) The dental-related services described in subsection (2) of this section unless the services are covered under the early periodic screening, diagnosis and treatment (EPSDT) program. See WAC 388-534-0100 for information about the EPSDT program.

     (b) Any service specifically excluded by statute.

     (c) More costly services when less costly, equally effective services as determined by the department are available.

     (d) Services, procedures, treatment, devices, drugs, or application of associated services:

     (i) Which the department or the centers for Medicare and Medicaid Services (CMS) considers investigative or experimental on the date the services were provided.

     (ii) That are not listed as covered in one or both of the following:

     (A) Washington Administrative Code (WAC).

     (B) The department's current published documents.

     (2) The department does not cover dental-related services listed under the following categories of service for clients through age twenty (see subsection (1)(a) of this section for services provided under the EPSDT program):

     (a) Diagnostic services. The department does not cover:

     (i) Extraoral radiographs.

     (ii) Comprehensive periodontal evaluations.

     (b) Preventive services. The department does not cover:

     (i) Nutritional counseling for control of dental disease.

     (ii) Tobacco counseling for the control and prevention of oral disease.

     (iii) Removable space maintainers of any type.

     (iv) Sealants placed on a tooth with the same-day occlusal restoration, preexisting occlusal restoration, or a tooth with occlusal decay.

     (v) Space maintainers for clients ages nineteen through twenty.

     (c) Restorative services. The department does not cover:

     (i) Gold foil restorations.

     (ii) Metallic, resin-based composite, or porcelain/ceramic inlay/onlay restorations.

     (iii) Crowns for cosmetic purposes (e.g., peg laterals and tetracycline staining).

     (iv) Crowns for third molars one, sixteen, seventeen, and thirty-two.

     (v) Temporary or provisional crowns (including ion crowns).

     (vi) Labial veneer resin or porcelain laminate restorations.

     (vii) Any type of coping.

     (viii) Crown repairs.

     (ix) Polishing or recontouring restorations or overhang removal for any type of restoration.

     (d) Endodontic services. The department does not cover:

     (i) Any endodontic therapy on primary teeth, except as described in WAC 388-535-1086 (3)(a).

     (ii) Apexification/recalcification for root resorption of permanent anterior teeth.

     (iii) Any apexification/recalcification procedures for bicuspid or molar teeth.

     (iv) Any apicoectomy/periradicular services for bicuspid or molar teeth.

     (v) Any surgical endodontic procedures including, but not limited to, retrograde fillings (except for anterior teeth), root amputation, reimplantation, and hemisections.

     (e) Periodontic services. The department does not cover:

     (i) Surgical periodontal services including, but not limited to:

     (A) Gingival flap procedures.

     (B) Clinical crown lengthening.

     (C) Osseous surgery.

     (D) Bone or soft tissue grafts.

     (E) Biological material to aid in soft and osseous tissue regeneration.

     (F) Guided tissue regeneration.

     (G) Pedicle, free soft tissue, apical positioning, subepithelial connective tissue, soft tissue allograft, combined connective tissue and double pedicle, or any other soft tissue or osseous grafts.

     (H) Distal or proximal wedge procedures.

     (ii) Nonsurgical periodontal services including, but not limited to:

     (A) Intracoronal or extracoronal provisional splinting.

     (B) Full mouth or quadrant debridement.

     (C) Localized delivery of chemotherapeutic agents.

     (D) Any other type of nonsurgical periodontal service.

     (f) Removable prosthodontics. The department does not cover:

     (i) Removable unilateral partial dentures.

     (ii) Any interim complete or partial dentures.

     (iii) Precision attachments.

     (iv) Replacement of replaceable parts for semi-precision or precision attachments.

     (g) Implant services. The department does not cover:

     (i) Any type of implant procedures, including, but not limited to, any tooth implant abutment (e.g., periosteal implant, eposteal implant, and transosteal implant), abutments or implant supported crown, abutment supported retainer, and implant supported retainer.

     (ii) Any maintenance or repairs to procedures listed in (g)(i) of this subsection.

     (iii) The removal of any implant as described in (g)(i) of this subsection.

     (h) Fixed prosthodontics. The department does not cover:

     (i) Any type of fixed partial denture pontic or fixed partial denture retainer.

     (ii) Any type of precision attachment, stress breaker, connector bar, coping, cast post, or any other type of fixed attachment or prosthesis.

     (i) Oral and maxillofacial surgery. The department does not cover:

     (i) Any oral surgery service not listed in WAC 388-535-1094.

     (ii) Any oral surgery service that is not listed in the department's list of covered current procedural terminology (CPT) codes published in the department's current rules or billing instructions.

     (j) Adjunctive general services. The department does not cover:

     (i) Anesthesia, including, but not limited to:

     (A) Local anesthesia as a separate procedure.

     (B) Regional block anesthesia as a separate procedure.

     (C) Trigeminal division block anesthesia as a separate procedure.

     (D) Medication for oral sedation, or therapeutic intramuscular (IM) drug injections, including antibiotic and injection of sedative.

     (E) Application of any type of desensitizing medicament or resin.

     (ii) Other general services including, but not limited to:

     (A) Fabrication of an athletic mouthguard.

     (B) Occlusion analysis.

     (C) Occlusal adjustment or odontoplasties.

     (D) Enamel microabrasion.

     (E) Dental supplies such as toothbrushes, toothpaste, floss, and other take home items.

     (F) Dentist's or dental hygienist's time writing or calling in prescriptions.

     (G) Dentist's or dental hygienist's time consulting with clients on the phone.

     (H) Educational supplies.

     (I) Nonmedical equipment or supplies.

     (J) Personal comfort items or services.

     (K) Provider mileage or travel costs.

     (L) Fees for no-show, cancelled, or late arrival appointments.

     (M) Service charges of any type, including fees to create or copy charts.

     (N) Office supplies used in conjunction with an office visit.

     (O) Teeth whitening services or bleaching, or materials used in whitening or bleaching.



[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1100, 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, § 388-535-1100, 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, § 388-535-1100, 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, § 388-535-1100, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1100, filed 12/6/95, effective 1/6/96.]