Service Descriptions and Limitations: Endodontic Services

The MassHealth agency pays for endodontic services including all radiographs performed with the exception of panoramic radiographs, during the treatment visit. The MassHealth agency pays for endodontic services for all MassHealth members in accordance with the service descriptions and limitations described in 130 CMR 420.426. (A) Pulpotomy. (1) The MassHealth agency pays for a therapeutic pulpotomy for members younger than 21 years old only. (2) Therapeutic pulpotomy is the surgical removal of a portion of the pulp with the aim of maintaining the vitality of the remaining portion by means of an adequate dressing. This procedure is performed on primary or permanent teeth. It is limited to instances when the prognosis is favorable, and must not be performed on primary teeth that are ready to exfoliate or permanent teeth with advanced periodontal disease or to be used for apexogenesis. (3) The MassHealth agency does not pay for pulpotomy on deciduous teeth that are ready to exfoliate. (4) The MassHealth agency does not pay for pulpotomy as the first stage of root canal therapy. (5) The MassHealth agency does not pay for a pulpotomy performed on the same date of service as root canal therapy. (See 130 CMR 420.456(C) regarding palliative treatment.) (B) Endodontic Root Canal Therapy. (1) General Conditions. (a) Payment by the MassHealth agency for root canal therapy includes payment for all preoperative and postoperative treatment; diagnostic (for example, pulp vitality) tests; and pretreatment, treatment, and post-treatment radiographs and anesthesia. MassHealth does not pay for pulpotomy as a separate procedure from root canal therapy. (b) The provider must maintain a radiograph of the completed root canal in the member’s dental record. (c) The MassHealth agency pays for root canal therapy on permanent anterior teeth, bicuspids, and first and second molars but does not pay for root canal therapy on third molars. Root canal therapy is limited to the permanent dentition only if the periodontal condition of the remaining dentition and soft tissue are stable with a favorable prognosis. (C) Endodontic Retreatment. (1) The MassHealth agency pays for endodontic retreatment of permanent anterior, bicuspids, and first and second molar teeth for all MassHealth members. This procedure may include the removal of a post, pins, old root canal filling material, and the procedures necessary to prepare the canals and place the canal filling. (2) Payment includes all retreatments within 24 months of the original root canal. (D) Apicoectomy/Periradicular Surgery. (1) The MassHealth agency pays for an apicoectomy as a separate procedure for all MassHealth members following root canal therapy when the canal cannot be retreated through reinstrumentation. (2) Payment by the MassHealth agency for an apicoectomy with root canal filling includes payment for the filling of the canal or canals and removing the pathological periapical tissue and any retrograde filling in the same period of treatment. (E) Pulp Cap. The MassHealth agency pays for indirect pulp cap on primary and permanent tooth to preserve tooth’s vitality once per tooth lifetime.