A. Dental services shall be covered for individuals younger than 21 years of age in fulfillment of the treatment requirements under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program and defined as routine diagnostic, preventive, or restorative procedures necessary for oral health provided by or under the direct supervision of a dentist in accordance with Chapter 27 (§ 54.1-2700 et seq.) of Title 54.1 of the Code of Virginia.

1. The Department of Medical Assistance Services (DMAS) will provide any medically necessary dental service to individuals younger than 21 years of age.

2. Certain dental services, as described in the DMAS Office Reference Manual (Smiles for Children, March 13, 2014), prepared by DMAS's dental benefits administrator, require preauthorization or prepayment review by DMAS or its designee.

3. Dental services for individuals younger than the age of 21 years that do not require preauthorization or prepayment review are initial, periodic, and emergency examinations; required radiography necessary to develop a treatment plan; patient education; dental prophylaxis; fluoride treatments; routine amalgam and composite restorations; stainless steel crowns, prefabricated steel post and temporary (polycarbonate) crowns, and stainless steel bands; crown recementation; pulpotomies; emergency endodontics for temporary relief of pain; pulp capping; sedative fillings; therapeutic apical closure; topical palliative treatment for dental pain; removal of foreign body; simple extractions; root recovery; incision and drainage of abscess; surgical exposure of the tooth to aid eruption; sequestrectomy for osteomyelitis; and oral antral fistula closure.

B. Dental services determined by the dental provider to be medically appropriate for an adult woman during the term of her pregnancy and through the end of the month following the 60th day postpartum shall be provided to a Medicaid-enrolled pregnant woman age 21 and older. The dental services that shall be covered are (i) diagnostic x-rays and exams; (ii) preventive cleanings; (iii) restorative fillings; (iv) endodontics (root canals); (v) periodontics (gum-related treatments); (vi) prosthodontics, both removable and fixed (crowns, bridges, partial plates, and dentures); (vii) oral surgery (tooth extractions and other oral surgeries and biopsies, alveoloplasty); and (viii) adjunctive general services (all covered services that do not fall into specific professional categories). These services require prepayment review by DMAS or its designee.

C. For the dental services covered for Medicaid-enrolled adult pregnant women, DMAS may place appropriate limits on a service based on medical necessity, for utilization control, or both. Examples of the following service limitations are shall apply: examinations, prophylaxis, fluoride treatment (once/six months); space maintenance appliances; bitewing x-ray - up to two four films (once/12 months); routine amalgam and composite restorations (once/three years) (once/12 months); dentures (once/five years); extractions, tooth guidance appliances, permanent crowns (once/60 months) and bridges, endodontics, patient education and sealants (once) endodontic (retreatments are not covered).

D. Dental services shall be provided to individuals with full-benefit Medicaid coverage, aged 21 and over.

1. The following services shall be covered: 1) dental exams, routine cleanings, x-rays; 2) fillings and crowns; 3) root canals and pulpal debridement; 4) scaling and root planning, gingivectomies, and periodontal maintenance procedures; 5) dentures, partials, and repair procedures; 6) extractions and alveoplasty; and 7) anesthesia services.

2. The following limits shall apply: 1) Prophylaxis shall be covered up to three times per year; 2) Non-routine x-rays such as imaging and cone beam technology require service authorization; 3) crowns are only covered when a root canal is done while member is covered under the adult dental program; 4) bridges are not covered; 5) endodontic retreatment, apexification, and apicoectomy are not covered ; 6) periodontal flap procedures, crown lengthening procedures, and bone replacement grafts are not covered; 7) partial dentures are covered only as a part of a definitive treatment plan and after a course of preventive and periodontal maintenance treatment; 8) oral antral fistulation procedures, closures of sinus perforations and dislocation and management of temporomandibular joint (TMJ) dysfunctions are not covered; 9) surgical trauma procedures that require CPT codes are not covered; 10) implants are not covered; 11) non-anesthesia adjunctive services may require service authorization.

D. E. Limited oral surgery procedures, as defined and covered under Title XVIII (Medicare), are covered for all recipients, and require preauthorization or prepayment review by DMAS or its designee as described in the agency's Office Reference Manual located on the DMAS website at http://www.dmas.virginia.gov/#/dentalresources.

E. F. Residents of nursing facilities shall be permitted to deduct the costs of limited specific dental procedures from their payments toward the costs of their nursing facility care. Nursing facility residents shall be limited to deducting the following dental procedures: (i) routine exams and x-rays and dental cleaning twice yearly; (ii) full mouth x-rays once every three years; and (iii) extractions and fillings shall be permitted only if medically necessary as determined by DMAS.