130 CMR 420.456 - Service Descriptions and Limitations: Other Services

(A) Hospital or Freestanding Ambulatory Surgical Center: Admission of Members with Certain Disabilities or Age-related Behavior for Restorative, Endodontic, or Exodontic Dentistry.

(1) The MassHealth agency pays for a member who is severely and chronically mentally and physically impaired, under certain circumstances, to undergo restorative, endodontic, or exodontic dental procedures for which they are eligible in a hospital or freestanding ambulatory surgery center. Use of these facilities may be indicated for a member who

(a) has a condition that is reasonably likely to place the member at risk of medical complications that require medical resources that are not available in an office setting; (b) is extraordinarily uncooperative, fearful, or anxious;

(c) has dental needs, but local anesthesia is ineffective due to acute infection, idiosyncratic anatomy, or allergy; or

(d) has sustained orofacial or dental trauma, or both, so extensive that treatment cannot be provided safely and effectively in an office setting.

(2) The member's medical record must include:

(a) a detailed description of the member's illness or disability;

(b) a history of previous treatment or attempts at treatment;

(c) a treatment plan listing all procedures and the teeth involved;

(d) radiographs (if radiographs are not available, an explanation is required);

(e) photographs to indicate the condition of the mouth if radiographs are not available; and

(f) documentation that there is no other suitable site of service for the member that would be less costly to the MassHealth agency.

(B) Behavioral Management. The MassHealth agency pays an additional payment once per member per day for management of a severely and chronically mentally, physically, or developmentally impaired member in the office. The provider must document a history of treatment or previous attempts at treatment in the member's medical record.

(C) Palliative Treatment of Dental Pain or Infection. The MassHealth agency pays for palliative treatment to alleviate dental pain or infection as part of an emergency service visit. Palliative treatment includes those services minimally required to address the immediate emergency including, but not limited to, draining of an abscess, prescribing pain medication or antibiotics, or other treatment that addresses the member's chief complaint. The provider must maintain in the member's dental record a description of the treatment provided and must document the emergent nature of the condition. The MassHealth agency pays separately for medically necessary covered services provided during the same visit.

(D) Occlusal Guard. The MassHealth agency pays for occlusal guards only for members younger than 21 years old and only once per calendar year. The MassHealth agency pays for only custom-fitted laboratory-processed occlusal guards designed to minimize the effects of bruxism (grinding) and other occlusal factors. All follow-up care is included in the payment.

(E) Mouth Guard for Sports. The MassHealth agency pays for custom-fitted mouth guards only for members younger than 21 years old once per calendar year. The provider must document the following information in the member's record: that the member is engaged in a contact sport (including, but not limited to basketball, football, hockey, lacrosse, and soccer) and there must be no other provision for the purchase of mouth guards for the sport's participants.

(F) House/Facility Call. The MassHealth agency pays for visits to nursing facilities, chronic disease and rehabilitation hospitals, hospice facilities, schools, and other licensed educational facilities, once per facility per day, in addition to any medically necessary MassHealth-covered service provided during the same visit.

Notes

130 CMR 420.456

Amended by Mass Register Issue 1342, eff. 6/30/2017. Amended by Mass Register Issue 1344, eff. 7/1/2017. Amended by Mass Register Issue 1454, eff. 10/15/2021.