OKDHS - OAC 317:30-5-696. Coverage by category

317:30-5-696. Coverage by category

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Revised 6-11-11

Payment is made for dental services as set forth in this Section.

(1) Adults.
- (A) Dental coverage for adults is limited to:
  - (i) emergency extractions;
  - (ii) Smoking and Tobacco Use Cessation Counseling; and
  - (iii) medical and surgical services performed by a dentist, to the extent such services may be performed under State law either by a doctor of dental surgery or dental medicine, when those services would be covered if performed by a physician.
- (B) Payment is made for dental care for adults residing in private Intermediate Care Facilities for the Mentally Retarded (ICF/MR) and who have been approved for ICF/MR level of care, similar to the scope of services available to individuals under age 21.
- (C) Pregnant women are covered under a limited dental benefit plan (Refer to (a)(4)of this Section).
(2) Home and community based waiver services (HCBWS) for the mentally retarded. All providers participating in the HCBWS must have a separate contract with the OHCA to provide services under the HCBWS. Dental services are defined in each waiver and must be prior authorized.
(3) Children. The OHCA Dental Program provides the basic medically necessary treatment. The services listed below are compensable for members under 21 years of age without prior authorization. ALL OTHER DENTAL SERVICES MUST BE PRIOR AUTHORIZED. Anesthesia services are covered for children in the same manner as adults. All providers performing preventive services must be available to perform needed restorative services for those members receiving any evaluation and preventive services.
- (A) Comprehensive oral evaluation. This procedure is performed for any member not seen by any dentist for more than 12 months.
- (B) Periodic oral evaluation. This procedure may be provided for a member of record if she or he has not been seen for more than six months.
- (C) Emergency examination/limited oral evaluation. This procedure is not compensable within two months of a periodic oral examination or if the member is involved in active treatment unless trauma or acute infection is the presenting complaint.
- (D) Radiographs (x-rays). To be SoonerCare compensable, x-rays must be of diagnostic quality and medically necessary. A clinical examination must precede any radiographs, and chart documentation must include member history, prior radiographs, caries risk assessment and both dental and general health needs of the member. The referring dentist is responsible for providing properly identified x-rays of acceptable quality with a referral, if that provider chooses to expose and submit for reimbursement prior to referral. Panoramic films are allowable once in a three year period and must be of diagnostic quality. Panoramic films are only compensable when chart documentation clearly indicates the test is being performed to rule out or evaluate non-caries related pathology. Prior authorization and a detailed medical need narrative are required for additional panoramic films taken within three years of the original set.

(E) Dental sealants. Tooth numbers 2, 3, 14, 15, 18, 19, 30 and 31 must be caries free on the interproximal and occlusal surfaces to be eligible for this service. This service is available through 18 years of age and is compensable only once per lifetime. Replacement of sealants is not a covered service under the SoonerCare program.
(F) Dental prophylaxis. This procedure is provided once every 184 days including topical application of fluoride.
(G) Composite restorations.
- (i) This procedure is compensable for primary incisors as follows:
  - (I) tooth numbers O and P to age 4 years;
  - (II) tooth numbers E and F to age 6 years;
  - (III) tooth numbers N and Q to 5 years; and
  - (IV) tooth numbers D and G to 6 years.
- (ii) The procedure is also allowed for use in all vital and successfully treated non-vital permanent anterior teeth.
- (iii) Class I and II composite restorations are allowed in posterior teeth; however, the OHCA has certain restrictions for the use of this restorative material. (See OAC 317:30-5-699).
(H) Amalgam. Amalgam restorations are allowed in:
- (i) posterior primary teeth when:
  - (I) 50 percent or more root structure is remaining;
  - (II) the teeth have no mobility; or

(III) the procedure is provided more than 12 months prior to normal exfoliation.

(ii) any permanent tooth, determined as medically necessary by the treating dentist.
- (I) Stainless steel crowns. The use of stainless steel crowns is allowed as follows:
(i) Stainless steel crowns are allowed if:
- (I) the child is five years of age or under;
- (II) 70 percent or more of the root structure remains; or
- (III) the procedure is provided more than 12 months prior to normal exfoliation.
(ii) Stainless steel crowns are treatment of choice for:
- (I) primary teeth with pulpotomies or pulpectomies, if the above conditions exist;
- (II) primary teeth where three surfaces of extensive decay exist; or
- (III) primary teeth where cuspal occlusion is lost due to decay or accident.
(iii) Stainless steel crowns are the treatment of choice on posterior permanent teeth that have completed endodontic therapy, if more than three surfaces of extensive decay exist or where cuspal occlusion are lost due to decay prior to age 16 years.
(iv) Preoperative periapical x-rays must be available for review, if requested.
(v) Placement of a stainless steel crown includes all related follow up service for a period of two years. No other prosthetic procedure on that tooth is compensable during that period of time. A stainless steel crown is not a temporizing treatment to be used while a permanent crown is being fabricated.

(J) Pulpotomies and pulpectomies.
- (i) Therapeutic pulpotomies are allowable for molars and teeth numbers listed below. Pre and post operative periapical x-rays must be available for review, if requested.
  - (I) Primary molars having at least 70 percent or more of their root structure remaining or more than 12 months prior to normal exfoliation;
  - (II) Tooth numbers O and P before age 5 years;
  - (III) Tooth numbers E and F before 6 years;
  - (IV) Tooth numbers N and Q before 5 years; and
  - (V) Tooth numbers D and G before 5 years.

(ii) Pulpectomies are allowed for primary teeth if exfoliation of the teeth is not expected to occur for at least one year or if 70 percent or more of root structure is remaining.

(K) Anterior root canals. Payment is made for the services provided in accordance with the following:
- (i) This procedure is done for permanent teeth when there are no other missing anterior teeth in the same arch requiring replacement.
- (ii) Acceptable ADA filling materials must be used.
- (iii) Preauthorization is required if the member's treatment plan involves more than four anterior root canals.
- (iv) Teeth with less than 50 percent of clinical crown should not be treatment-planned for root canal therapy.
- (v) Pre and post operative periapical x-rays must be available for review.
- (vi) Pulpotomy may be performed for the relief of pain while waiting for the decision from the OHCA.
- (vii) Providers are responsible for any follow-up treatment required due to a failed root canal therapy for 24 month post completion.
- (viii) Endodontic treated teeth should be restored to limited occlusal function and all contours should be replaced. These teeth are not automatically approved for any type of crown.
- (ix) If there are three or more missing teeth in the arch that requires replacement, root therapy will not be allowed.
(L) Space maintainers. Certain limitations apply with regard to this procedure. Providers are responsible for recementation of any maintainer placed by them for six months post insertion.
- (i) Band and loop type space maintenance. This procedure must be provided in accordance with the following guidelines:
  - (I) This procedure is compensable for all primary molars where permanent successor is missing or where succedaneous tooth is more than 5mm below the crest of the alveolar ridge or where the successor tooth would not normally erupt in the next 12 months.

(II) First primary molars are not allowed space maintenance if the second primary and first permanent molars are present and in cuspal interlocking occlusion regardless of the presence or absence of normal relationship.
(III) If there are missing teeth bilaterally in the same arch, under the above guidelines, bilateral space maintainer is the treatment of choice.
(IV) The teeth numbers shown on the claim should be those of the missing teeth.
(V) Post operative bitewing x-rays must be available for review.
(VI) Bilateral band and loop space maintainer is allowed if member does not have eruption of the four mandibular anterior teeth in position or if sedation case that presents limitations to fabricate other space maintenance appliances.

(ii) Lingual arch bar. Payment is made for the services provided in accordance with the following:
- (I) Lingual arch bar is used when permanent incisors are erupted and multiple missing teeth exist in the same arch.
- (II) The requirements are the same as for band and loop space maintainer.
- (III) Multiple missing upper anterior primary incisors may be replaced with the appliance to age 6 years to prevent abnormal swallowing habits.
- (IV) Pre and post operative x-rays must be available.
(iii) Interim partial dentures. This service is for anterior permanent tooth replacement or if the member is missing three or more posterior teeth to age 16 years of.

(M) Analgesia. Analgesia services are reimbursable in accordance with the following:
- (i) Inhalation of nitrous oxide. Use of nitrous oxide is compensable for four occurrences per year and is not separately reimbursable, if provided on the same date by the same provider as IV sedation, non-intravenous conscious sedation or general anesthesia. The need for this service must be documented in the member's record. This procedure is not covered when it is the dentist's usual practice to offer it to all patients.
- (ii) Non-intravenous conscious sedation. Non-intravenous conscious sedation is not separately reimbursable, if provided on the same date by the same provider as analgesia, anxiolysis, inhalation of nitrous oxide, IV sedation or general anesthesia. Non-intravenous conscious sedation is reimbursable when determined to be medically necessary for documented handicapped members, uncontrollable members or justifiable medical or dental conditions. The report must detail the member's condition. No services are reimbursable when provided primarily for the convenience of the member and /or the dentist, it must be medically necessary.
(N) Pulp caps. Indirect and direct pulp cap must be ADA accepted materials, not a cavity liner. Indirect and direct pulp cap codes require specific narrative support addressing materials used, intent and reasons for use. Application of chemicals used for dentinal hypersensitivity is not allowed as indirect pulp cap. Utilization of these codes is verified by post payment review.
(O) Sedative restorations. Sedative restorations include removal of decay, if present, and direct or indirect pulp cap, if needed. These services are reimbursable for the same tooth on the same date of service. Permanent restoration of the tooth is allowed after 30 days unless the tooth becomes symptomatic and requires pain relieving treatment.
(P) History and physical. Payment is made for services for the purpose of admitting a patient to a hospital for dental treatment.
(Q) Local anesthesia. This procedure is included in the fee for all services.
(R) Smoking and Tobacco Use Cessation Counseling. Smoking and Tobacco Use Cessation Counseling is covered when performed utilizing the five intervention steps of asking the member to describe his/her smoking, advising the member to quit, assessing the willingness of the member to quit, assisting with referrals and plans to quit, and arranging for follow-up. Up to eight sessions are covered per year per individual who has documented tobacco use. It is a covered service when provided by physicians, physician assistants, nurse practitioners, nurse midwives, and Oklahoma State Health Department and FQHC nursing staff in addition to other appropriate services rendered. Chart documentation must include a separate note, separate signature, and the member specific information addressed in the five steps and the time spent by the practitioner performing the counseling. Anything under three minutes is considered part of a routine visit.

(4) Pregnant Women. Dental coverage for this special population is provided regardless of age.
- (A) Proof of pregnancy is required (Refer to OAC 317:35-5-6).
- (B) Coverage is limited to a time period beginning at the diagnosis of pregnancy and ending upon 60 days post partum.
- (C) In addition to dental services for adults, other services available include:
  - (i) Comprehensive oral evaluation must be performed and recorded for each new member, or established member not seen for more than 24 months;
  - (ii) Periodic oral evaluation as defined in OAC 317:30-5-696(3)(B);
  - (iii) Emergency examinations/limited oral evaluation. This procedure is not allowed within two months of an oral examination by the same provider for the same member, or if the member is under active treatment;
  - (iv) Radiographs as defined in OAC 317:30-5-696(3)(D);
  - (v) Dental prophylaxis as defined in OAC 317:30-5-696(3)(F);
  - (vi) Composite restorations:
    - (I) Any permanent tooth that has an opened lesion that is a food trap will be deemed medically necessary for this program and will be allowed for all anterior teeth.
    - (II) Class I posterior composite resin restorations are allowed in posterior teeth that qualify;
  - (vii) Amalgam. Any permanent tooth that has an opened lesion that is a food trap will be deemed as medically necessary and will be allowed; and
  - (viii) Analgesia. Analgesia services are reimbursable in accordance with OAC 317:30-5-696(iii)(M).
- (D) Services requiring prior authorization (Refer to OAC 317:30-5-698).
- (E) Periodontal scaling and root planing. Required that 50% or more of six point measurements be 5 millimeters or greater. This procedure is designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins and microorganism and requires anesthesia and some soft tissue removal.
(5) Individuals eligible for Part B of Medicare.
- (A) Payment is made based on the member's coinsurance and deductibles.
- (B) Services which have been denied by Medicare as non-compensable should be filed directly with the OHCA with a copy of the Medicare EOB indicating the reason for denial.

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