WAC 388-535-1267   Covered dental-related services for clients age twenty-one and older -- Oral and maxillofacial surgery services.  The department covers oral and maxillofacial surgery 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) Oral and maxillofacial surgery services. The department:

     (a) Requires enrolled dental providers who do not meet the conditions in WAC 388-535-1070(3) to bill claims for services that are listed in this subsection using only the current dental terminology (CDT) codes.

     (b) Requires enrolled providers (oral and maxillofacial surgeons) who meet the conditions in WAC 388-535-1070(3) to bill claims using current procedural terminology (CPT) codes unless the procedure is specifically listed in the department's current published billing instructions as a CDT covered code (e.g., extractions).

     (c) Does not cover oral surgery services described in WAC 388-535-1267 that are performed in a hospital operating room or ambulatory surgery center.

     (d) Requires the client's record to include supporting documentation for each type of extraction or any other surgical procedure billed to the department. The documentation must include:

     (i) An appropriate consent form signed by the client or the client's legal representative;

     (ii) Appropriate radiographs;

     (iii) Medical justification with diagnosis;

     (iv) Client's blood pressure, when appropriate;

     (v) A surgical narrative;

     (vi) A copy of the post-operative instructions; and

     (vii) A copy of all pre- and post-operative prescriptions.

     (e) Covers routine and surgical extractions.

     (f) Covers debridement of a granuloma or cyst that is five millimeters or greater in diameter. The department includes debridement of a granuloma or cyst that is less than five millimeters as part of the global fee for the extraction.

     (g) Covers biopsy, as follows:

     (i) Biopsy of soft oral tissue or brush biopsy do not require prior authorization; and

     (ii) All biopsy reports must be kept in the client's record.

     (h) Covers alveoloplasty only when three or more teeth are extracted per arch.

     (i) Covers surgical excision of soft tissue lesions only on a case-by-case basis and when prior authorized.

     (j) Covers only the following excisions of bone tissue in conjunction with placement of immediate, complete, or partial dentures when prior authorized:

     (i) Removal of lateral exostosis;

     (ii) Removal of torus palatinus or torus mandibularis; and

     (iii) Surgical reduction of soft tissue or osseous tuberosity.

     (2) Surgical incision-related services. The department covers the following surgical incision-related services:

     (a) Uncomplicated intraoral and extraoral soft tissue incision and drainage of abscess. The department does not cover this service when combined with an extraction or root canal treatment. Documentation supporting medical necessity must be in the client's record; and

     (b) Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue when prior authorized. Documentation supporting medical necessity must be in the client's record.



[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-041, § 388-535-1267, filed 3/1/07, effective 4/1/07.]