CHAPTER 505 ORAL HEALTH SERVICES — Covered Services (505.1)
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Defines West Virginia Medicaid coverage, provider requirements, prior authorization, documentation, and limits for oral health services for members, including special rules for those under and over age 21.
No material clinical or coverage changes in this revision.
Coverage Criteria
Age-based coverage criteria
Covered when the conditions below are met, by age group and service type:
Dental periodic screenings follow AAPD and Bright Futures recommendations; prior authorization may be required for specific services and when limits are exceeded.
If more than one comprehensive orthodontic procedure code is billed for a member, the claim will deny.
Orthodontic services require prior authorization from the UMC regardless of primary insurance.
Prior authorization may be required for specific emergent services and when service limits are exceeded.
Members are responsible for costs exceeding the limit; remaining balances at the end of the fiscal period cannot be carried over.
Local anesthesia and oral sedation are considered part of the treatment procedure and may not be billed separately.
This section identifies categories of dental services that West Virginia Medicaid does not cover. Non-covered categories include experimental or investigational services or services provided for research purposes, removal of primary teeth when exfoliation is imminent, and any dental services for which prior authorization has been denied or was not obtained. Coverage is also excluded for services provided solely for the convenience of the member, the member’s caretaker, or the provider, and for procedures performed for cosmetic purposes.
Specific examples of non-covered services include: experimental/investigational or research-related procedures; extraction of primary teeth when their exfoliation is imminent; services lacking required prior authorization or where prior authorization was denied; procedures billed by providers not enrolled with West Virginia Medicaid; and use of an unlisted code when a national CDT code exists or billing unbundled CDT codes instead of the appropriate bundled code.
West Virginia Medicaid does not cover services provided for appearance-only reasons. Examples include adult cosmetic procedures and other treatments that lack documented medical necessity. The policy also excludes anesthesia when provided solely for convenience of the member, caretaker, or provider; note that local anesthesia and oral sedation are considered part of the treatment procedure and may not be billed separately.
Certain non-covered services are not eligible for administrative appeal. Non-covered services listed in this chapter are not eligible for a West Virginia DHHR Fair Hearing or Desk/Document review; see 42 § 431.220 for details when a hearing is required.
Coding and Limits
| CPT (fluoride varnish when billed by non-dental providers) | Fluoride varnish applications must be billed with appropriate CPT codes when provided by eligible primary care providers in conjunction with a comprehensive well-child exam. |
| CDT (fluoride varnish when billed by dental providers) | Fluoride varnish applications billed by dental providers must use the appropriate CDT code on dental claim form. |
| CPT/CDT (dual-degree practitioners) | Dual-degree practitioners may bill CPT or CDT procedure codes within their scope; may bill a combination of appropriate CPT and CDT codes for services provided, but duplicate billing of the same service with CPT and CDT is not allowed. |
Provider Actions, Prior Authorization & Documentation
Obtain prior authorization for orthodontics and services beyond limits
Prior authorization is required for orthodontic services, for services when service limits are exceeded, for CDT codes listed in the chapter appendices, and for all inpatient hospitalizations; prior authorization requests are submitted to the utilization management contractor (UMC) and do not guarantee approval or payment.
- Orthodontic services for members under 21 must be medically necessary and require prior authorization with clinical documentation (treatment plan, radiographs, photos) available to the UMC.
- If a CDT code requires prior authorization, the service requires prior authorization regardless of place of service.
- Refer to Chapter 505, Appendix A and Appendix B for the list of covered services, specific procedure codes requiring prior authorization, and service limits.
Request retrospective authorization only in specified circumstances
Retrospective prior authorization may be granted by the UMC only when a primary payer denied the procedure after the provider has followed the primary payer's requirements including appeals, or when Medicaid eligibility is granted retroactively.
- Retrospective authorization is available only in the two specified circumstances: primary payer denial after appeals, or retroactive Medicaid eligibility.
Non‑covered if prior authorization denied or not obtained
Dental services for which prior authorization has been denied or was not obtained are considered non-covered and may be denied for payment.
- Prior authorization requests do not guarantee approval or payment; lack of prior authorization can render a service non-covered.
Document behavior guidance failure and credentials for anesthesia coverage
Anesthesia (general anesthesia, conscious sedation, or anxiolysis) is covered only after demonstration that basic behavior guidance techniques have failed or are inappropriate due to immaturity or disability, or when sedation is needed to protect the developing psyche or reduce medical risk; anesthesia must be performed in conjunction with other covered services.
- Provider must hold the appropriate anesthesia permit/certificate from the West Virginia Board of Dental Examiners or the state board where they practice for the level of anesthesia used.
- Local anesthesia and oral sedation are considered part of the treatment and may not be billed separately.
Maintain and provide complete clinical documentation and prior authorization
Maintain and submit all required clinical documentation to support requests and claims, including referrals, diagnosis with appropriate CDT code, and treatment plans; ensure prior authorization is obtained when applicable.
- Keep a referral for treatment on file.
- Record the primary diagnosis and appropriate CDT code for the service to be provided.
- For orthodontics, retain the treatment plan, radiographs, photos, and any dental molds as appropriate and make them available to the UMC for prior authorization review.
- Include documentation to justify medical necessity and the ADA claim form when submitting for payment.
Retain referral, diagnosis with CDT code, orthodontic treatment plan, and supporting records
Providers must maintain specific documentation for dental services, including a referral, primary diagnosis with the appropriate CDT code, a treatment plan for orthodontics, radiographs, photos or dental molds when appropriate, documentation justifying medical necessity, and prior authorization when applicable.
- Submit the ADA claim form for payment consideration when appropriate.
- Follow additional documentation requirements in Chapter 100 and Chapter 300.
Do not bill local anesthesia or oral sedation separately
Local anesthesia and oral sedation are considered part of the treatment procedures and may not be billed separately.
- Do not submit separate charges for local anesthesia or oral sedation; include them in the primary procedure billing.
Avoid billing multiple comprehensive orthodontic procedure codes; prior auth is not a payment guarantee
Claims will deny if more than one comprehensive orthodontic procedure code is billed for the same member; additionally, submitting a prior authorization request does not guarantee payment.
- Ensure only one comprehensive orthodontic treatment code is billed per lifetime per member to avoid denial.
- Confirm that prior authorization approval is received before providing services to reduce risk of denial, but recognize approval does not guarantee payment.
Services without prior authorization or with denied authorization risk denial
Services for which prior authorization has not been obtained or has been denied are non-covered and may be denied; obtaining prior authorization is the provider's responsibility before rendering services that require it.
- Verify prior authorization requirements (including inpatient hospitalizations) and secure approval from the UMC when required to reduce denial risk.
Background
West Virginia Medicaid provides oral health benefits that vary by age and clinical need. Members <21 years old are eligible for a broad set of services — diagnostic, preventive, restorative, periodontic, prosthodontic, oral and maxillofacial surgery, and orthodontics when medically necessary — while adults 21 and older receive coverage focused on emergent care and diagnostic/preventive/restorative services subject to limits and prior authorization. Coverage decisions reference professional guidance and require documentation of medical necessity; services may be delivered in office, ambulatory surgical center, outpatient or inpatient hospital settings as appropriate.
Definitions
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