(1) For purposes of specifying coverage of dental services through the Medicaid program, the department adopts and incorporates by reference the Dental and Denturist Program Provider Manual effective October 2007. The Dental and Denturist Program Provider Manual informs the providers of the requirements applicable to the delivery of services. Copies of the manual are available on the Montana Medicaid provider web site at http://medicaidprovider.hhs.mt.gov and from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(2) Dentists who are Medicaid provider participants under ARM 37.85.401 may bill medical CPT procedure codes as provided in ARM 37.85.212 and 37.86.101 for any Medicaid covered medical procedure that they are allowed to provide under the Dental Practice Act that is not otherwise listed in the Dental and Denturist Program Provider Manual.

(3) All services which require prior authorization from the designated review organization are identified in the department's fee schedule. Reimbursement is not provided for such services unless prior authorization has been given by the designated review organization.

(4) A licensed dental hygienist practicing under public health supervision may provide dental hygiene preventative services as defined by the Board of Dentistry.

(5) Covered services for adults age 21 and over include:

(a) diagnostic;

(b) preventative;

(c) basic restorative services including prefabricated crowns; and

(d) extractions.

(6) Full maxillary and full mandibular dentures are a Medicaid covered service. Coverage is limited to one set of dentures every ten years. Only one lifetime exception to the ten year time period is allowed per recipient if one of the following exceptions is authorized by the department:

(a) The dentures are no longer serviceable and cannot be relined or rebased.

(b) The dentures are lost, stolen, or damaged beyond repair.

(7) Maxillary partial dentures and mandibular partial dentures are a Medicaid covered service. Coverage is limited to one set ofpartial dentures every five years. Only one lifetime exception to the five year limit is allowed per recipient if one of the following exceptions is authorized by the department:

(a) The partial dentures are no longer serviceable and cannot be relined or rebased.

(b) The partial dentures are lost, stolen, or damaged beyond repair.

(8) The limits on coverage of denture replacement may be exceeded when the department determines that the existing dentures are causing the recipient serious physical health problems.

(a) The dentist or denturist must indicate "replacement dentures" on the request for prior authorization of replacement dentures and document the medical necessity for the replacement.

(9) Coverage of denture services are subject to the following requirements and limitations:

(a) A denturist may provide initial immediate full prosthesis and initial immediate partial prosthesis only when prescribed by a dentist.

(b) Requests for full prosthesis must show the approximate date of the most recent extractions, and/or the age and type of the present prosthesis.

(10) Orthodontia for recipients age 21 and older who have maxillofacial anomalies that must be corrected surgically and for which the orthodontia is a necessary adjunct to the surgery is a covered service.

(11) Full band orthodontia for recipients 21 and younger who have malocclusion caused by traumatic injury or needed as part of treatment for a medical condition with orthodontic implications are covered in the department's Dental and Denturist Program Provider Manual.

(12) Unless otherwise provided by these rules, interceptive orthodontia is limited to children 12 years of age or younger with one or more of the following conditions:

(a) posterior crossbite with shift;

(b) anterior crossbite.

(13) All full band orthodontia for cleft lip/palate, congenital anomalies, cases related to malocclusion caused by traumatic injury and cases related to interceptive orthodontia must receive prior authorization from the department's designated peer reviewer to determine individual eligibility for such orthodontia services.

(14) Orthodontic treatment not progressing to the extent of the treatment plan because of noncompliance by the recipient and which jeopardizes the health of the recipient may result in termination of orthodontic treatment. If termination of orthodontic treatment occurs because of noncompliance by the recipient, Medicaid will not authorize any future orthodontic requests for that recipient.

(15) Cosmetic dentistry is not a covered service of the Medicaid program.

(16) Dental implants are not a covered benefit of the Medicaid program.

(17) Porcelain/ceramic crowns, noble metal crowns, and bridges are not covered benefits of the Medicaid program for individuals age 21 and over.