WAC 388-535-1271   Dental-related services not covered for clients age twenty-one and older.  (1) The department does not cover the following for clients age twenty-one and older (see WAC 388-535-1065 for dental-related services for clients eligible under the GA-U or ADATSA program):

     (a) The dental-related services and procedures described in subsection (2) of this section;

     (b) Any service specifically excluded by statute;

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

     (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 published documents (e.g., billing instructions).

     (2) The department does not cover dental-related services listed under the following categories of service for clients age twenty-one and older:

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

     (i) Detailed and extensive oral evaluations or re-evaluations;

     (ii) Comprehensive periodontal evaluations;

     (iii) Extraoral or occlusal intraoral radiographs;

     (iv) Posterior-anterior or lateral skull and facial bone survey films;

     (v) Sialography;

     (vi) Any temporomandibular joint films;

     (vii) Tomographic survey;

     (viii) Cephalometric films;

     (ix) Oral/facial photographic images;

     (x) Viral cultures, genetic testing, caries susceptibility tests, adjunctive prediagnostic tests, or pulp vitality tests; or

     (xi) Diagnostic casts.

     (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) Oral hygiene instructions (included as part of the global fee for oral prophylaxis);

     (iv) Removable space maintainers of any type;

     (v) Sealants;

     (vi) Space maintainers of any type or recementation of space maintainers; or

     (vii) Fluoride trays of any type.

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

     (i) Restorative/operative procedures performed in a hospital operating room or ambulatory surgical center for clients age twenty-one and older. For clients of the division of developmental disabilities, see WAC 388-535-1099;

     (ii) Gold foil restorations;

     (iii) Metallic, resin-based composite, or porcelain/ceramic inlay/onlay restorations;

     (iv) Prefabricated resin crowns;

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

     (vi) Any type of permanent or temporary crown. For clients of the division of developmental disabilities see WAC 388-535-1099;

     (vii) Recementation of any crown, inlay/onlay, or any other type of indirect restoration;

     (viii) Sedative fillings;

     (ix) Preventive restorative resins;

     (x) Any type of core buildup, cast post and core, or prefabricated post and core;

     (xi) Labial veneer resin or porcelain laminate restoration;

     (xii) Any type of coping;

     (xiii) Crown repairs; or

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

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

     (i) Indirect or direct pulp caps;

     (ii) Endodontic therapy on any primary teeth for clients age twenty-one and older;

     (iii) Endodontic therapy on permanent bicuspids or molar teeth;

     (iv) Any apexification/recalcification procedures;

     (v) Any apicoectomy/periradicular service; or

     (vi) Any surgical endodontic procedures including, but not limited to, retrograde fillings, root amputation, reimplantation, and hemisections.

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

     (i) Surgical periodontal services that include, but are not limited to:

     (A) Gingival or apical flap procedures;

     (B) Clinical crown lengthening;

     (C) Any type of 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; or

     (H) Distal or proximal wedge procedures; or

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

     (A) Intracoronal or extracoronal provisional splinting;

     (B) Full mouth debridement;

     (C) Localized delivery of chemotherapeutic agents; or

     (D) Any other type of nonsurgical periodontal service.

     (f) Prosthodontics (removable). The department does not cover any type of:

     (i) Removable unilateral partial dentures;

     (ii) Adjustments to any removable prosthesis;

     (iii) Chairside complete or partial denture relines;

     (iv) Any interim complete or partial denture;

     (v) Precision attachments; or

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

     (g) Oral and maxillofacial prosthetic services. The department does not cover any type of oral or facial prosthesis other than those listed in WAC 388-535-1266.

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

     (i) Any 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 (h)(i) of this subsection; or

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

     (i) Prosthodontics (fixed). The department does not cover any type of:

     (i) Fixed partial denture pontic;

     (ii) Fixed partial denture retainer;

     (iii) Precision attachment, stress breaker, connector bar, coping, or cast post; or

     (iv) Other fixed attachment or prosthesis.

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

     (i) Any nonemergency oral surgery performed in a hospital or ambulatory surgical center for current dental terminology (CDT) procedures;

     (ii) Vestibuloplasty;

     (iii) Frenuloplasty/frenulectomy;

     (iv) Any oral surgery service not listed in WAC 388-535-1267;

     (v) 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;

     (vi) Any type of occlusal orthotic splint or device, bruxing or grinding splint or device, temporomandibular joint splint or device, or sleep apnea splint or device; or

     (vii) Any type of orthodontic service or appliance.

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

     (i) Anesthesia to include:

     (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) Analgesia or anxiolysis as a separate procedure except for inhalation of nitrous oxide;

     (E) Medication for oral sedation, or therapeutic drug injections, including antibiotic or injection of sedative; or

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

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

     (A) Fabrication of athletic mouthguard, occlusal guard, or nightguard;

     (B) Occlusion analysis;

     (C) Occlusal adjustment or odontoplasties;

     (D) Enamel microabrasion;

     (E) Dental supplies, including but not limited to, 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) Missed or late appointment fees;

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

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

     (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. 07-06-041, § 388-535-1271, filed 3/1/07, effective 4/1/07.]