Final Text
12VAC30-50-190. Dental services.
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 the State Dental Practice Act Chapter 27 (ยง 54.1-2700 et seq.)
of Title 54.1 of the Code of Virginia.
1. The state agency 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 agency's
DMAS Office Reference Manual (Smiles for Children, March 13, 2014),
prepared by DMAS' DMAS's dental benefits administrator, require
preauthorization or prepayment review by the state agency 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) 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. 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 (viii) adjunctive general services
(all covered services that do not fall into specific professional categories).
These services require prepayment review by the state agency DMAS
or its designee.
C. For the dental services covered for Medicaid-enrolled adult
pregnant women, the state agency DMAS may place appropriate
limits on a service based on medical necessity, for utilization control, or
both. Examples of service limitations are: examinations, prophylaxis,
fluoride treatment (once/six months); space maintenance appliances; bitewing
x-ray - two films (once/12 months); routine amalgam and composite restorations
(once/three years); dentures (once/five years); extractions, tooth guidance
appliances, permanent crowns and bridges, endodontics, patient education and
sealants (once).
D. Limited oral surgery procedures, as defined and covered
under Title XVIII (Medicare), are covered for all recipients, and require
preauthorization or prepayment review by the state agency DMAS or
its designee as described in the agency's Office Reference Manual located on
the DMAS website at: http://www.dmas.virginia.gov/Content_atchs/dnt/VA_SFC_ORM_140313.pdf
http://www.dmas.virginia.gov/#/dentalresources.
E. 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.