Covered and Noncovered Services: Introduction

(A) Medically Necessary Services. The MassHealth agency pays for the following dental services when medically necessary: (1) the services with codes listed in Subchapter 6 of the Dental Manual, in accordance with the service descriptions and limitations described in 130 CMR 420.422 through 420.456; and (2) all services for EPSDT-eligible members, in accordance with 130 CMR 450.140 through 450.149, without regard for the service limitations described in 130 CMR 420.422 through 420.456, or the listing of a code in Subchapter 6. All such services are available to EPSDT- eligible members, with prior authorization, even if the limitation specifically applies to other members younger than 21 years old. (B) Noncovered Services. The MassHealth agency does not pay for the following services for any member, except when MassHealth determines the service to be medically necessary and the member is younger than 21 years old. Prior authorization must be submitted for any medically necessary noncovered services for members younger than 21 years old. (1) cosmetic services; (2) certain dentures including unilateral partials, overdentures and their attachments, temporary dentures, CuSil-type dentures, other dentures of specialized designs or techniques, and preformed dentures with mounted teeth (teeth that have been set in acrylic before the initial impressions); (3) counseling or member education services; (4) habit-breaking appliances; (5) implants of any type or description; (6) laminate veneers; (7) oral hygiene devices and appliances, dentifrices, and mouth rinses; (8) orthotic splints, including mandibular orthopedic repositioning appliances; (9) panoramic films for crowns, endodontics, periodontics, and interproximal caries; (10) root canals filled by silver point technique, or paste only; (11) tooth splinting for periodontal purposes; and (12) any other service not listed in Subchapter 6 of the Dental Manual. (C) Covered Services for All Members 21 Years of Age or Older. The MassHealth agency pays for the services listed in 130 CMR 420.422 through 420.456 for all members 21 years of age or older in accordance with the service descriptions and limitations set forth therein: (1) diagnostic services as described in 130 CMR 420.422; (2) radiographs as described in 130 CMR 420.423; (3) preventive services as described in 130 CMR 420.424; (4) restorative services as described in 130 CMR 420.425; (5) endodontic services as described in 130 CMR 420.426; (6) periodontal services as described in 130 CMR 420.427; (7) prosthodontic services as described in 130 CMR 420.428; (8) oral surgery services as described in 130 CMR 420.430; (9) anesthesia services as described in 130 CMR 420.452; (10) oral and maxillofacial surgery services as described in 130 CMR 420.453; (11) maxillofacial prosthetics as described in 130 CMR 420.455; (12) behavior management services as described in 130 CMR 420.456(B); (13) palliative treatment of dental pain or infection services as described in 130 CMR 420.456(C); and (14) house/facility call as described in 130 CMR 420.456(F). (D) Noncovered Services for Members 21 Years of Age or Older. The MassHealth agency does not pay for the following services for members 21 years of age and older: (1) preventive services as described in 130 CMR 420.424(C); (2) prosthodontic services (fixed) as described in 130 CMR 420.429; and (3) other services as described in 130 CMR 420.456(A), (B), (E), and (F).