Emergency Text
12VAC30-50-190. Dental services.
A. Dental services are limited to recipients under shall
be covered for individuals younger than 21 years of age in fulfillment of
the treatment requirements under the Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) Program and defined as routine diagnostic, preventive, or
restorative procedures necessary for oral health provided by or under the
direct supervision of a dentist in accordance with the State Dental Practice
Act.
B. Certain dental services, as described in the
agency's Office Reference Manual (Smiles for Children, copyright 2005) March
13, 2014), prepared by DMAS' dental benefits administrator, require
preauthorization or prepayment review by the state agency or its designee.
C. Dental services, determined by the dental provider to be appropriate for a woman during the term of her pregnancy, shall be provided to a Medicaid-enrolled pregnant woman. The dental services that shall be covered are (i) diagnostic x-rays and exams; (ii) preventive cleanings; (iii) restorative fillings; (iv) endodontics (root canals); (v) periodontics (gum related treatments); (vi) prosthodontics, both removable and fixed (crowns, bridges, partial plates, and dentures); (vii) oral surgery (tooth extractions and other oral surgeries); and (viii) adjunctive general services (all covered services that do not fall into specific professional categories). These services require prepayment review by the state agency or its designee.
C. The D. For the dental services covered for
individuals younger than 21 years of age and for Medicaid-enrolled pregnant
women, the state agency may place appropriate limits on a service based on
medical necessity, for utilization control, or both. Examples of service
limitations are: examinations, prophylaxis, fluoride treatment (once/six
months); space maintenance appliances; bitewing x-raytwo films (once/12
months); routine amalgam and composite restorations (once/three years);
dentures (once/five years); extractions, orthodontics, tooth guidance
appliances, permanent crowns and bridges, endodontics, patient education and
sealants (once).
D. E. Limited oral surgery procedures, as
defined and covered under Title XVIII (Medicare), are covered for all
recipients, and require preauthorization or prepayment review by the state
agency or its designee as described in the agency's Office Reference Manual
located on the DMAS website at: (http://www.dmas.virginia.gov/downloads/pdfs/dental-office_reference_manual_06-09-05.pdf)
http://www.dmas.virginia.gov/
DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-50)
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition DSM-IV-TR, copyright 2000, American Psychiatric Association
Length of Stay by Diagnosis and Operation, Southern Region, 1996, HCIA, Inc.
Guidelines for Perinatal Care, 4th Edition, August 1997, American Academy of Pediatrics and the American College of Obstetricians and Gynecologists
Virginia Supplemental Drug Rebate Agreement Contract and Addenda
Office Reference Manual (Smiles for Children), prepared by
DMAS' Dental Benefits Administrator, copyright 2005
(www.dmas.virginia.gov/downloads/pdfs/dental-office_reference_manual_06-09-05.pdf).
Office Reference Manual (Smiles for Children), prepared by
DMAS' Dental Benefits Administrator, copyright 2010, dated March 13, 2014 (http://www.dmas.virginia.gov/
Patient Placement Criteria for the Treatment of Substance-Related Disorders ASAM PPC-2R, Second Edition, copyright 2001, American Society of Addiction Medicine
12VAC30-141-820. Benefit packages.
Pregnant women covered through FAMIS MOMS may receive the same medical and dental services and are subject to the same limitations on services as pregnant women (see 12VAC30-50-190) covered by the Medicaid program as defined in 12VAC30-10-140 and 12VAC30-50-10.