Subpart
1.
Definitions.
For the purposes of this part, the following terms have the
meanings given them.
A. "Crown" means
a restoration covering or replacing the major part or the whole portion of the
tooth not covered by supporting tissues.
B. "Dental service" means a diagnostic,
preventive, or corrective procedure furnished by or under the supervision of a
dentist.
C. "Fixed partial denture"
or "fixed cast metal restoration" or "fixed bridge" means a prosthetic
replacement of one or more missing teeth that is cemented or attached to the
abutment adjacent to the space filled by the prosthetic replacement and that
cannot be removed by the patient.
D. "Implant" means material inserted or
grafted into tissue or bone; or a device specially designed to be placed
surgically within or on the mandibular or maxillary bone as a means of
providing for dental replacement.
E. "Oral hygiene instruction" means an
organized education program carried out by or under the supervision of a
dentist to instruct a patient about the care of the patient's teeth.
F. "Rebase" means the process of refitting a
denture by replacing the base material.
G. "Reline" means the process of resurfacing
the tissue side of the denture with a new base material.
H. "Removable prosthesis" or "removable
dental prosthesis" includes dentures and removable partial dentures and means
any dental device or appliance replacing one or more missing teeth, including
associated structures, if required, that is designed to be removed and
reinserted by the patient.
Subp.
2.
Covered dental services.
A covered dental service is any dental service that meets the
general requirements for MA-covered services in part
9505.0210, subject to the limits
in this part and the requirements in parts
9505.5010 and
9505.5030 that apply when prior
authorization is a condition of payment. Services that require authorization
are published in the State Register as required by Minnesota Statutes, section
256B.0625,
subdivision 25. The list of services requiring authorization is continuously
updated in the Minnesota Health Care Program (MHCP) providers' manual issued by
the Minnesota Department of Human Services and is incorporated by reference.
The manual is available on line at www.dhs.state.mn.us under the bulletins,
publications, and manuals selection. The Web site may be accessed through a
computer at a public library. The services in items A to S indicate the scope
of covered services but are not an exclusive or exhaustive list of covered
services. When individual medical need requires a service that is not listed in
this subpart, a provider has the option of seeking prior authorization for the
service under parts
9505.5010 and
9505.5030 unless the service is an
excluded dental service under subpart
10.
A. oral hygiene instruction;
B. fluoride treatment;
C. panoramic film;
D. dental x-rays;
E. dental prophylaxis;
F. sealants;
G. oral evaluation;
H. full mouth debridement;
I. behavior management, which in dental
terminology, is a documented service that is necessary to ensure that a covered
dental procedure is performed correctly and safely;
J. space maintainer;
K. oral surgery and extractions;
L. fillings;
M. endodontic therapy and periodontic
therapy;
N. removable partial
dentures;
O. removable
dentures;
P. crowns that meet the
specifications in subpart
2a, item G;
Q. orthodontic treatment that meets the
specifications in subpart
2a, item F;
R. reline or rebase of a removable denture;
and
S. dental implants that meet
the criteria in subpart
2a, item H.
Subp. 2a.
Payment limits on
covered dental services.
Payment for some of the covered dental services listed in
subpart
2 is limited as specified in
items A to H.
A. Initial placement or
replacement of a removable prosthesis is limited to once every three years per
patient unless a condition in subitem (1) or (2) applies:
(1) Replacement of a removable prosthesis in
excess of the limit in item A is eligible for payment if the replacement is
necessary because the removable prosthesis was misplaced, stolen, or damaged
due to circumstances beyond the patient's control. When applicable, the
patient's degree of physical and mental impairment must be considered in
determining whether the circumstances were beyond a patient's
control.
(2) Replacement of a
partial prosthesis is eligible for payment if the existing prosthesis cannot be
modified or altered to meet the patient's dental needs.
B. Service for a removable prosthesis must
include instruction in the use and care of the prosthesis and any adjustment
necessary to achieve a proper fit during the six months immediately following
the provision of the prosthesis. The dentist shall document the instruction and
the necessary adjustments, if any, in the patient's dental record.
C. All criteria under subitems (1) to (3)
must be met in order for a provider to receive payment for a cast metal
removable prosthesis:
(1) the crown to root
ratio must be better than 1:1;
(2)
the surrounding abutment teeth and the remaining teeth must not have extensive
tooth decay; and
(3) the abutment
teeth must not have large restorations or stainless steel crowns.
D. The criteria in subitems (1) to
(4) must be met in order to receive payment for periodontal scaling and root
planing:
(1) evidence of bone loss must be
present on the current radiographs - panoramic, full mouth series or bitewing -
to support the diagnosis of periodontitis;
(2) there must be current periodontal
charting with six point and mobility noted, including the presence of pathology
and periodontal prognosis;
(3) the
pocket depths must be greater than four millimeters; and
(4) classification of the periodontology case
type must be in accordance with documentation established by the American
Academy of Periodontology.
E. Hospitalization coverage for dental
surgeries and services is subject to parts
9505.0501 to
9505.0545, which establish a
system for reviewing the use of inpatient hospital services.
F. At least one of the following criteria
must be met in order to receive payment for orthodontic treatment:
(1) there is a disfigurement of the patient's
facial appearance including protrusion of upper or lower jaws or
teeth;
(2) there is spacing between
adjacent teeth which interferes with the biting function;
(3) there is an overbite to the extent that
the lower anterior teeth impinge on the roof of the mouth when the person
bites;
(4) positioning of jaws or
teeth impairs chewing or biting function; or
(5) based on a comparable assessment of
subitems (1) to (4), there is an overall orthodontic problem that interferes
with the biting function.
G. Except as medically necessary in
conjunction with a fixed bridge covered by this part or an implant covered by
this part, an individual crown must be made of prefabricated stainless steel,
prefabricated resin, or laboratory resin in order to be covered.
H. The criteria in subitems (1) to (3) must
be met in order to receive payment for dental implants and related services:
(1) there must be bone and tooth loss that
compromises chewing or breathing;
(2) the implants must be medically necessary
and cost-effective; and
(3) a
complete treatment plan, including prosthesis and all related services, must be
approved prior to the start of treatment.
Subp. 3. [Repealed, 26 SR 1630]
Subp. 4. [Repealed, 26 SR 1630]
Subp. 5. [Repealed, 26 SR 1630]
Subp. 6. [Repealed, 26 SR 1630]
Subp. 7. [Repealed, 26 SR 1630]
Subp. 8. [Repealed, 26 SR 1630]
Subp. 9. [Repealed, 26 SR 1630]
Subp. 10.
Excluded dental
services.
The dental services in items A to L are not eligible for
payment under the medical assistance program:
A. pulp caps;
B. a local anesthetic that is used in
conjunction with an operative or surgical procedure and billed as a separate
procedure;
C. hygiene aids,
including toothbrushes;
D.
medication dispensed by a dentist that a patient is able to obtain from a
pharmacy;
E. acid etch for a
restoration that is billed as a separate procedure;
F. prosthesis cleaning;
G. removable unilateral partial denture that
is a one-piece cast metal including clasps and teeth;
H. dental services for cosmetic or aesthetic
purposes;
I. fixed partial denture
or fixed bridge, unless it has been determined to be medically necessary and
cost-effective for a patient who cannot use a removable prosthesis due to a
mental or physical medical condition;
J. replacement of a denture when a reline or
rebase would correct the problem;
K. gold restoration or inlay, including cast
nonprecious and semiprecious metals; and
L. implants and related services when the
conditions and criteria in subpart
2a, item H, are not
met.
