Minn. R. agency 196, ch. 9505, MEDICAL ASSISTANCE PAYMENTS, pt. 9505.0270

Current through Register Vol. 49, No. 24, December 9, 2024

Part 9505.0270 - DENTAL SERVICES

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.

Minn. R. agency 196, ch. 9505, MEDICAL ASSISTANCE PAYMENTS, pt. 9505.0270

12 SR 624; 26 SR 1630

Statutory Authority: MS s 256B.04