CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

Medicaid Dental Services

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This rule governs Medicaid reimbursement for dental services furnished to District of Columbia Medicaid beneficiaries, including children, adults, and adults residing in an ICF/IID or enrolled in the applicable HCBS waiver. It establishes covered and excluded services, provider requirements, medical-necessity criteria, prior-authorization requirements, documentation standards, and reimbursement limitations.

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyMedicaid Dental Services

Policy CodePolicy N/A

Change TypeRevised

Effective DateDecember 23, 2016

Next Review DateN/A

Key ActionObtain prior authorization before delivering orthodontic services to a beneficiary under 21.

SourceLink

POLICY UPDATE CHANGES

Section 964 of Title 29 DCMR was deleted in its entirety and replaced with revised Medicaid dental-service rules.

The rule clarifies the criteria and documentation required for prior authorization of orthodontic services, dental implants, and removable-prosthesis replacement.

Under 21Beneficiaries eligible for dental services under EPSDT

15+ HLD scoreAutomatic orthodontic eligibility threshold

4 maxillary / 2 mandibular

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CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

Medicaid Dental Services

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Sign up for all District of Columbia Department of Health Care Finance policy alerts

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Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyMedicaid Dental Services

Policy CodePolicy N/A

Change TypeRevised

Effective DateDecember 23, 2016

Next Review DateN/A

Key ActionObtain prior authorization before delivering orthodontic services to a beneficiary under 21.

SourceLink

POLICY UPDATE CHANGES

Section 964 of Title 29 DCMR was deleted in its entirety and replaced with revised Medicaid dental-service rules.

The rule clarifies the criteria and documentation required for prior authorization of orthodontic services, dental implants, and removable-prosthesis replacement.

Under 21Beneficiaries eligible for dental services under EPSDT

15+ HLD scoreAutomatic orthodontic eligibility threshold

4 maxillary / 2 mandibular

Maximum implants authorized for a completely edentulous beneficiary

5 yearsReplacement limitation for dentures, removable prostheses, and dental implants, subject to exceptions

21 and olderAdult population-specific covered and excluded service rules

4 mmMinimum periodontal pocket depth for covered scaling and root planing

Covered Dental Services and Eligibility

Children under 21 and EPSDT

Covered for Medicaid beneficiaries under 21 as an EPSDT benefit when services are provided at standard dental-practice intervals or when medically necessary to evaluate a suspected condition.

EPSDT dental benefit: Services must include, at minimum, preventive services, relief of pain and infections, restoration of teeth, and maintenance of dental health.

Covered population is Medicaid beneficiaries under 21.

Orthodontic services

Orthodontic services for beneficiaries under 21 are covered when prior authorization is obtained and at least one of the following pathways is met.

Orthodontic eligibility pathways

HLD pathway: The beneficiary has an adjusted Handicapping Labio-Lingual Deviation (HLD) Index score greater than or equal to 15.HLD >= 15
Automatic qualifying condition pathway: The beneficiary has one or more listed automatic qualifying conditions that causes dysfunction due to a handicapping malocclusion and is supported by evidence in the beneficiary's treatment records.At least 1 condition
Conditions include cleft palate deformity; cranio-facial anomaly; deep impinging overbite causing destruction of palatal soft tissue with tissue laceration and/or clinical attachment loss; crossbite of individual anterior teeth causing clinical attachment loss with gingival recession; severe traumatic deviation; or overjet greater than 9 millimeters or mandibular protrusion greater than 3.5 millimeters.
Other medical-need pathway: The beneficiary has at least two specified medical-need conditions and an accompanying narrative justifying orthodontic treatment from the ordering or referring dentist, orthodontist, primary care physician, speech pathologist, or behavioral health provider.At least 2 conditions
Conditions include treatment-resistant speech pathology diagnosed by a licensed speech therapist; dysfunctional masticatory capacity; significant facial asymmetry; severe maxillary, mandibular, or bi-maxillary protrusion or other physical deviation; or another objectively evidenced condition affecting medical, social, or emotional function.

Adult periodontal scaling and root planing

Adult periodontal scaling and root planing is covered when all listed clinical documentation and disease criteria are met.

Periodontal scaling and root planing

Radiographic bone loss: Current radiographs, a full-mouth x-ray series, or bitewing x-rays show bone loss supporting the diagnosis of periodontitis.
Periodontal charting: Current periodontal charting includes six-point measurements, mobility, pathology, and periodontal prognosis.6-point measurements
Pocket depth: Periodontal pocket depths are greater than 4 millimeters.> 4 mm

Adult dental implants

Adult dental implants are covered only with prior authorization and when all applicable implant requirements are met.

Dental implant criteria

Permanent tooth replacement: The implant will replace a permanent tooth or teeth.
Periodontal disease control: Any active periodontal disease is treated and under control before the request.
Caries and endodontic treatment: Existing teeth with caries and endodontic lesions are treated before the request.
Opposing occlusion: The tooth or teeth to be replaced have an opposing occlusion.

For Medicaid beneficiaries 21 and older, the policy expressly excludes separately billed local anesthesia used with surgery, hygiene aids, cosmetic or aesthetic procedures, over-the-counter medications dispensed by a dentist, separately billed acid etch, gold restorations and related inlays or onlays, duplicative x-rays, space maintainers, denture replacement when reline or rebase would correct the problem, prosthesis cleaning, one-piece cast-metal removable unilateral partial dentures, and dental implants replacing wisdom teeth. Fixed prosthodontics, such as a bridge, is excluded unless prior authorized.

Clinical Thresholds and Authorization Parameters

Orthodontic qualification threshold

HLD IndexAdjusted score greater than or equal to 15

Index nameHandicapping Labio-Lingual Deviation (HLD) Index

UseQualifying pathway for orthodontic treatment

Automatic orthodontic qualification

Overjet thresholdGreater than 9 millimeters

Qualification typeAutomatic Qualifying Condition

Required supportThe condition must cause dysfunction due to a handicapping malocclusion and be supported by treatment records

Authorization, Documentation, and Billing Requirements

Prior Authorization

Under-18 Dental Implants Require Prior Authorization

Obtain prior authorization from DHCF or its agent before providing dental implants to a Medicaid beneficiary under age 18.

Prior Authorization

Orthodontic Prior Authorization and Eligibility

Before delivering orthodontic services to a Medicaid beneficiary under age 21, obtain prior authorization and document that the beneficiary meets at least one qualifying pathway.

Adjusted HLD Index score ≥ 15.
An Automatic Qualifying Condition causing dysfunction from handicapping malocclusion, supported in the treatment record.
An established medical need supported by at least two qualifying conditions and an accompanying narrative from an appropriate ordering or referring provider.

Policy Scope and Benefit Context

The District of Columbia Medicaid dental benefit covers children and specified adult populations. Medicaid beneficiaries under 21 receive enhanced dental coverage through EPSDT, including preventive services, relief of pain and infections, restoration of teeth, and maintenance of dental health when provided at standard dental-practice intervals or when medically necessary to evaluate a suspected condition.

Adult dental services are governed by population-specific coverage, reimbursement, documentation, frequency, and prior-authorization requirements. These rules apply to beneficiaries age 21 and older, including those who reside in an ICF/IID or are enrolled in the applicable HCBS waiver; qualifying services for those populations may be reimbursed at the increased rate specified by DHCF.

Defined Terms

Definitions

DeviceA device specially designed for dental replacement

PlacementPlaced surgically within or on the mandibular or maxillary bone

PurposeProviding for dental replacement

Definitions

ProfessionA person licensed as a dental hygienist

District of Columbia licensureLicensed pursuant to the District of Columbia Health Occupations Revisions Act of 1985

Other jurisdictionMay be licensed as a dental hygienist in the jurisdiction where the services are provided

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyMedicaid Dental Services

Policy CodePolicy N/A

Change TypeRevised

Effective DateDecember 23, 2016

Next Review DateN/A

Key ActionObtain prior authorization before delivering orthodontic services to a beneficiary under 21.

SourceLink

On This Page

Case classification: The periodontology case type is classified in accordance with American Academy of Periodontology guidelines.

Automatic orthodontic qualification

Mandibular protrusion thresholdGreater than 3.5 millimeters

Qualification typeAutomatic Qualifying Condition

Required supportThe condition must cause dysfunction due to a handicapping malocclusion and be supported by treatment records

Alternative orthodontic medical-need pathway

Minimum conditionsTwo or more specified medical-need conditions

DocumentationAn accompanying narrative must justify the need for orthodontic treatment

Authorized sourcesNarrative may be prepared by the ordering or referring dentist, orthodontist, primary care physician, speech pathologist, or behavioral health provider

Periodontal treatment threshold

Pocket depthGreater than 4 millimeters

Covered servicePeriodontal scaling and root planing

Additional requirementCurrent periodontal charting must include six-point measurements, mobility, pathology, and periodontal prognosis

Implant site requirement

Minimum interdental spaceAt least 3 millimeters

Measurement locationBetween the requested implant site and adjacent roots

PurposeTo maintain periodontal health and form

Implant prophylaxis requirement

Prophylaxis timingThe most recent oral prophylaxis must be no more than 6 months before the request

DocumentationPeriodontal charting, radiographic documentation, and oral hygiene status must be submitted

ServiceDental implant prior authorization

Completely edentulous implant authorization

Maxillary archFour dental implants

Mandibular archTwo dental implants

Eligibility contextAuthorization applies to a completely edentulous beneficiary

Documentation Required

Orthodontic Medical-Necessity Records

Submit evidence supporting the orthodontic eligibility pathway before treatment. Records must substantiate the HLD score, an Automatic Qualifying Condition, or the alternative medical-need pathway.

Automatic Qualifying Conditions include cleft palate, cranio-facial anomaly, destructive deep impinging overbite, qualifying anterior crossbite, severe traumatic deviation, or overjet >9 mm or mandibular protrusion >3.5 mm.
The alternative pathway may include treatment-resistant speech pathology, dysfunctional masticatory capacity, significant facial asymmetry, severe protrusion or physical deviation, or another objectively supported medical, social, or emotional functional condition.
For the alternative pathway, include a narrative from the ordering or referring dentist, orthodontist, primary care physician, speech pathologist, or behavioral health provider; speech pathology must be diagnosed by a licensed speech therapist.

Prior Authorization

Hospitalization or General Anesthesia Requires Prior Authorization

Any dental service provided to a Medicaid beneficiary in connection with inpatient hospitalization or general anesthesia must be prior authorized by DHCF or its agent.

Secure authorization before furnishing or billing the related dental service.

Prior Authorization

Adult Dental Implant Requirements

For beneficiaries age 21 and older, obtain prior authorization for dental implants and ensure all clinical requirements are met before submitting the request.

Implants must replace permanent teeth.
Treat and control active periodontal disease before requesting implants.
Treat existing caries and endodontic lesions before requesting implants.
The tooth or teeth being replaced must have an opposing occlusion.
For a completely edentulous beneficiary, authorization is limited to four maxillary implants and two mandibular implants.

Billing Rule

Prosthesis Frequency Limits and Exceptions

Apply the prosthesis frequency limits unless additional services are prior authorized.

Initial removable prosthesis: one per arch every five years per beneficiary, unless prior authorized.
Denture reline or rebase: one per five-year period, unless additional services are prior authorized.
A completely edentulous beneficiary may be authorized for four maxillary and two mandibular dental implants, subject to the implant criteria and prior authorization.

Prior Authorization

Implant Replacement Requires Prior Authorization

Dental implants may not be replaced within five years of initial placement unless prior authorization is obtained from DHCF or its agent.

Document the date of initial placement and include the justification for any replacement request.

Prior Authorization

Fixed Prosthodontics Requires Prior Authorization

Fixed prosthodontics, including bridges, is excluded for adult beneficiaries unless prior authorized.

Obtain authorization before furnishing or billing a bridge or other fixed prosthodontic service.

Step Therapy

Consider Conservative Alternatives Before Implants

Before requesting implants, consider less invasive treatment when adjacent teeth require crowns or have significant disease or injury, or when multiple teeth are missing.

Evaluate whether conservative treatment can address the condition and replace all missing teeth.
Explain in the clinical justification why the conservative alternative is unsuitable when implants are requested.

Step Therapy

Repair Before Replacement

Do not request denture replacement when adjusting, relining, or rebasing the existing denture would correct the problem.

If a significant medical condition is alleged to have caused poor fit, submit the required physician or surgeon letter and the dentist's statement that the denture cannot be made functional by adjustment, relining, or rebasing.

Documentation Required

Dental Implant Documentation

Include complete clinical support with every dental implant prior authorization request.

Clinical justification, including why conventional removable dentures cannot replace the missing teeth.
Medical-history summary addressing systemic, behavioral, psychological, neurologic, and psychiatric conditions and habits that may affect surgery, healing, or treatment response.
Evaluation of proximity to vital structures, including sinuses, fossae, foramina, mandibular canals, adjacent teeth, and roots.
Periodontal charting; radiographs; absence of clinical calculus; oral-hygiene status; and the date of oral prophylaxis, which must be within six months of the request.
Documentation of adequate alveolar-bone and soft-tissue quality, mass, and density.
Documentation of at least 3 mm of interdental space between the implant site and adjacent roots.
Complete restorative treatment plan.

Documentation Required

Periodontal Charting and Radiographs

For periodontal scaling and root planing, document current disease findings in the prior authorization or treatment record.

Current radiographs, full-mouth series, or bitewing radiographs showing bone loss supporting periodontitis.
Current periodontal charting with six-point measurements, mobility, pathology, and periodontal prognosis.
Pocket depths greater than 4 mm.
Periodontology case classification consistent with American Academy of Periodontology guidelines.

Documentation Required

Removable-Prosthesis Replacement Records

For a removable-prosthesis replacement request, obtain and submit the beneficiary's signed letter and all required identifying and clinical information.

Beneficiary letter must state the reason for replacement and include the D.C. Medicaid number, date, home address, telephone number, and signature.
For replacement attributed to a significant medical condition, include a physician or surgeon letter documenting the condition and a dentist letter stating that adjustment, relining, or rebasing cannot make the existing denture functional.

Denial Risk

Orthodontic Authorization or Eligibility Failure

Orthodontic services are not reimbursable when required prior authorization is missing or when the beneficiary does not meet and document an eligible pathway.

Denial risk includes treatment delivered before authorization.
Denial risk includes failure to establish HLD ≥15, an Automatic Qualifying Condition, or the alternative medical-need pathway.

Denial Risk

Implant Authorization or Criteria Failure

Implant services may be denied when prior authorization, clinical criteria, or required supporting documentation is missing.

Obtain authorization before implant placement or replacement when required, including replacement within five years of initial placement.
Demonstrate permanent-tooth replacement, controlled periodontal disease, treated caries and endodontic lesions, and opposing occlusion.
Submit the complete implant clinical, medical, periodontal, radiographic, anatomical, bone-and-soft-tissue, spacing, and restorative-plan documentation.

Denial Risk

Periodontal Documentation Failure

Periodontal scaling and root planing may be denied when the required radiographic or periodontal evidence is absent or insufficient.

Missing current radiographic evidence of bone loss.
Missing six-point periodontal measurements, mobility, pathology, or prognosis.
Pocket depths not greater than 4 mm or missing case-type classification.

Denial Risk

Unjustified Denture Replacement

Denture replacement may be denied when the existing prosthesis is repairable or when frequency and documentation requirements are not satisfied.

Replacement is not covered when relining or rebasing would correct the problem.
Initial removable prostheses are limited to one per arch every five years unless prior authorized.
A required beneficiary letter, identifying information, or medical-condition documentation is missing.

Denial Risk

Excluded Adult Dental Services

Adult beneficiaries age 21 and older are not eligible for expressly excluded dental services.

Examples include cosmetic or aesthetic procedures, separately billed local anesthesia with surgery, hygiene aids, duplicative x-rays, space maintainers, prosthesis cleaning, specified removable unilateral partial dentures, and dental implants replacing wisdom teeth.
Fixed prosthodontics such as bridges is excluded unless prior authorized.

Denial Risk

Provider Eligibility Requirements

Medicaid reimbursement requires an eligible dental provider. Except for children's fluoride varnish, services must be furnished by a dentist or dental hygienist working under dentist supervision.

Practice must be within the provider's authorized scope under the applicable professional-practice law.
Provider must have a current D.C. Medicaid Provider Agreement authorizing billing for dental services for the covered population.

Definitions

ProfessionA person licensed as a dentist

District of Columbia licensureLicensed pursuant to the District of Columbia Health Occupations Revisions Act of 1985

Other jurisdictionMay be licensed as a dentist in the jurisdiction where the services are provided

Definitions

EntityA dental facility

Enrollment requirementEnrolled as a District Medicaid provider

ProgramDistrict Medicaid

Definitions

SettingTreatment in a hospital

Minimum stayRequires at least one overnight stay

ClassificationInpatient hospitalization

Definitions

Service typeMedically appropriate services

Clinical purposeNecessary to correct severe handicapping malocclusion

Eligible beneficiariesBeneficiaries under the age of twenty-one

Definitions

Document typeA written plan

Required contentDiagnostic findings and treatment recommendations

BasisResults from a comprehensive evaluation of the dental health needs of a beneficiary