HAR §17-1737-75. Dental services

(a) Dental services means diagnostic, preventive, and corrective procedures administered because of a diseased condition, injury, or impairment, by or under the supervision of a dentist licensed under state law for the treatment of teeth and the associated structures of the oral cavity. (b) Dental services for individuals under the age of twenty-one are limited to the following services: (1) Emergency treatment which includes services to relieve dental pain, eliminate infection, and treatment of acute injuries to the teeth and supporting structures of the oro-facial complex; (2) X-ray with the limitations of one set of two bitewing rediographs during a twelve-month period and one set of full month rediographs during a five-year period, including bitewings; (3) Preventive dental services: (A) Topical application of fluoride; (B) Sealants for occlusal surface of permanent molar teeth only for children ages six through fifteen; and (C) Dental examination and prophylaxis treatment, which shall be limited to not more than once every six months, and which shall not cover routine examination of institutional patients; (4) Periodontic treatment limited to cases of medical necessity, includes in the procedure, post operative care for six months following treatment and recall treatment limited to three times a year. Prior authorization and a medical report is required: Osseous and mucogingival surgeries, grafts, and implants are considered elective and are not covered; (5) Dental work done under conscious sedation (inhalation or intravenous) or general anesthesia shall be allowed only in cases of UNOFFICIAL 1737-84 medical necessity and within program policy guidelines. A medical report is required; (6) Root canal therapy with the following requirements: (A) Root canal therapy shall be covered for a maximum of once per tooth, except in cases of poor prognosis, as in the case of advanced decay or bone loss or prior root canal failure. Completed root canal x-rays shall be submitted with the claim for payment; (B) Root canal therapy shall not be covered for the purpose of overdenture fabrication except under special medical circumstances which requires prior authorization and a medical report; (7) Extraction, whether done in the dentist's office or in a hospital under general anesthesia; (8) Restorative dentistry with the following limitations: (A) Restorative dentistry shall be limited to the use of amalgam, silicate, resin, plastic, acrylic, or composite fillings; (B) Non-duplicated restorative procedures are allowed only once per tooth every two years as needed in the treatment of fractured or carious teeth; (C) Acrylic jackets and acrylic veneer crowns, if authorized, shall be limited to anterior teeth for a maximum of once per tooth; (D) The department shall not allow a separate charge for tooth preparation, temporary restorations, pulp caps, cement bases, impressions, or local anesthesia; (E) An amalgam or composite buildup shall be considered a component part of the preparation for the completed restoration except in special circumstances, and by report; and (F) Amalgam restorations are allowed, but composite resin or acrylic restorations in posterior secondary teeth (except the facial surface of permanent first premolars) shall be considered purely cosmetic dentistry and shall not be covered; UNOFFICIAL 1737-85 (9) Drugs administered by the dentist in the dentist's office shall be covered at the rate of fifty cents for each drug plus the cost of the drug; (10) Dental prosthesis limited to crowns, space maintainers, partial or full dentures, adjustments and repair, subject to the following limitations: (A) Partial dentures shall be limited to fill the space due to the loss of one or more anterior teeth and to fill the space due to the loss of two or more posterior teeth exclusive of third molars; (B) One partial or full denture shall be allowed per arch per recipient in any five year period. This is allowed when existing dentures cannot be repaired or adjusted; (C) Temporary partial dentures shall be allowed only when teeth have been extracted recently and shall be subject to the maximum benefits for dentures; (D) Denture relines are limited to one per denture every two years; (E) Precious, semi-precious, and non-precious metal cast crowns shall be limited to permanent first and second molars; (F) Overdentures shall not be covered; and (G) Space maintainers are limited to children age fourteen and under to hold the space for the eruption of the permanent cuspids, pre-molars or first molars due to premature loss of the deciduous predecessor; and (11) Consultation and dental surgery with the following limitations: (A) Routine postoperative visits shall be considered part of the total surgical procedure and shall not be separately compensable; and (B) Vestibuloplastys, skin grafts, bone grafts, and implants shall not be covered except when one or more is part of the treatment for fractured jaws. (c) Specific dental services not covered by the department shall include the following: (1) Orthodontic services except following repair of a cleft palate or other severe UNOFFICIAL 1737-86 developmental defect or injury in a child for which the functions of speech, swallowing, or chewing shall be restored; (2) Fixed bridge work; (3) Plaque control; (4) Gold inlays; (5) Gold crowns, except for permanent first and second molars; (6) Procedures, appliances, or restorations solely for cosmetic purposes. Composite resin or acrylic restoration in posterior teeth and all primary teeth shall be considered purely cosmetic; and (7) Overdentures. (d) Dental services for individuals twenty-one years and older are limited to emergency treatment which does not include services aimed at restoring and replacing teeth and shall include services for the following: (1) Relief of dental pain; (2) Elimination of infection; and (3) Treatment of acute injuries to the teeth or supporting structures of the oro-facial complex. [Eff 08/01/94; am 01/29/96; am 03/30/96; am 06/19/00; am 04/11/03; am 12/07/06,am 08/10/09,am ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §440.100)