37.86.1006 : DENTAL SERVICES, COVERED PROCEDURES - Administrative Rules of the State of Montana

37.86.1006 DENTAL SERVICES, COVERED PROCEDURES

(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 as provided in ARM 37.85.105(3). 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.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;

(d) extractions; and

(e) porcelain fused to base metal crowns, and porcelain/ceramic crowns are limited to two per person per year, total. For second molars, base metal crowns only.

(6) Medically necessary dental services outlined in (5)(c) through (e), excluding anesthesia services, are subject to an annual limit of $1,125 per benefit year. A benefit year begins on July 1st and ends the following June 30th. Members determined categorically eligible for Aged, Blind, and Disabled (ABD) Medicaid, in accordance with ARM 37.82.204, are not subject to the annual limit.

(7) 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 person if one of the following exceptions is authorized by the department:

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

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

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

(a) The partial dentures are no longer serviceable and can no longer be relined or rebased; or

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

(9) The limits on coverage of denture replacement may be exceeded when the department determines that the existing dentures are causing the person serious physical health problems. The dentist or denturist should indicate "replacement dentures" on the request for prior authorization of replacement dentures and document the medical necessity for the replacement.

(10) Coverage of all denture services is subject to the following requirements and limitations:

(a) A denturist may provide initial immediate full prosthesis and initial immediate partial prosthesis only when prescribed in writing by a dentist. The prescription must be signed and dated within 90 days of the order and must be maintained in the patient file.

(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.

(11) Orthodontia for persons 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.

(12) Full band comprehensive orthodontic or interceptive orthodontic treatment for persons 20 and younger who have one of the following handicapping conditions, indicated with an 'X' on the HLD score sheet:

(a) cleft palate;

(b) deep impinging overbite;

(d) who score a 30 or higher without a handicapping condition (as listed above) on the Handicapping Labio-Lingual Form (HLD Index).

(13) 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 unilateral crossbite;

(b) bilateral crossbite; or

(14) All orthodontia treatment plans must receive prior authorization from the department's designated peer reviewer to determine individual eligibility for such orthodontia services.

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

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

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

(18) Nobel metal crowns, and bridges are not covered benefits of the Medicaid program for individuals age 21 and over.

History: 53-2-201, 53-6-113, MCA; IMP, 53-6-101, 53-6-113, MCA; NEW, 1990 MAR p. 1331, Eff. 7/13/90; AMD, 1993 MAR p. 2433, Eff. 10/15/93; AMD, 1995 MAR p. 1968, Eff. 10/1/95; AMD, 1999 MAR p. 1522, Eff. 7/2/99; AMD, 1999 MAR p. 2898, Eff. 12/17/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 1664, Eff. 6/30/00; AMD, 2002 MAR p. 1780, Eff. 6/28/02; AMD, 2005 MAR p. 1073, Eff. 7/1/05; AMD, 2006 MAR p. 1894, Eff. 7/28/06; AMD, 2007 MAR p. 1824, Eff. 11/9/07; AMD, 2009 MAR p. 1017, Eff. 7/1/09; AMD, 2010 MAR p. 2986, Eff. 1/1/11; AMD, 2013 MAR p. 1111, Eff. 7/1/13; AMD, 2015 MAR p. 2315, Eff. 1/1/16; AMD, 2018 MAR p. 458, Eff. 3/1/18; AMD, 2018 MAR p. 2057, Eff. 10/20/18; AMD, 2019 MAR p. 1640, Eff. 10/1/19.