WAC 388-535-1255   Covered dental-related services -- Adults.  The department covers dental-related diagnostic services only as listed in this section for clients age twenty-one and older (for dental-related services provided to clients eligible under the GA-U or ADATSA program, see WAC 388-535-1065).

     (1) Clinical oral evaluations. The department covers:

     (a) Oral health evaluations and assessments. The services must be documented in the client's record in accordance with WAC 388-502-0020;

     (b) Periodic oral evaluations as defined in WAC 388-535-1050, once every twelve months. Twelve 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 an additional limited oral examination by a denturist for the same client until three months after the 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 evaluation services;

     (ii) Performed to determine the need for 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 required.

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

     (c) Covers 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 in the client's record.

     (e) Covers up to four bitewing radiographs once in a twelve month period.

     (f) 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.

     (g) 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.



[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-041, § 388-535-1255, 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. 03-19-079, § 388-535-1255, filed 9/12/03, effective 10/13/03.]