Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter DEN-91 September 2013 TO: Dental Providers Participating in MassHealth FROM: Kristin L. Thorn, Acting Medicaid Director RE: Dental Manual (Revised Regulations about Dental Sealants) This letter transmits revised regulations modifying language to reflect that MassHealth will no longer pay for sealants on primary (baby) molars as described in 130 CMR 420.424(C). MassHealth continues to pay for sealants on permanent, noncarious, nonrestored molars for members under age 17. These regulations are effective October 1, 2013. MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e- mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Dental Manual Pages 4-13 and 4-14 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Dental Manual Pages 4-13 and 4-14 — transmitted by Transmittal Letter DEN-90 ? Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 420.000) Page 4-13 Dental Manual Transmittal Letter DEN-91 Date 10/01/13 (C) Sealants. (1) The MassHealth agency pays for sealants, which includes proper preparation of the enamel surface, etching, placement and finishing of the sealant, and reapplication if the process fails within three years. The MassHealth agency does not pay to replace sealants lost or damaged during the three-year period when reapplied by the same provider. The MassHealth agency does not pay for sealants applied to any tooth that has been restored or for sealants for primary (deciduous) molars. (2) The MassHealth agency pays only for sealants that meet all of the following requirements: (a) for permanent noncarious nonrestored molars; (b) for members who are under age 17; and (c) only once every three years per noncarious nonrestored molar. (D) Space Maintainers. The MassHealth agency pays for space maintainers and replacement space maintainers. Space maintainers are indicated when there is premature loss of teeth that may lead to loss of arch integrity. For primary cuspids, space maintainers prevent midline deviation and loss of arch length and circumference. Premature loss of primary molars also indicates the use of space maintainers to prevent the migration of adjacent teeth. The loss of primary incisors usually does not require the use of a space maintainer. An initial diagnostically acceptable radiograph must be maintained in the member’s record, demonstrating that the tooth has not begun to erupt or that migration of the adjacent tooth has already occurred. The provider must maintain in the member’s record, diagnostic-quality radiographs that support the need for space maintainers whether initial or replacement. Payment for subsequent visits to adjust space maintainers is included in the original payment. 420.425: Service Descriptions and Limitations: Restorative Services The MassHealth agency pays for restorative services for members under age 21 and DDS clients only in accordance with the service descriptions and limitations in 130 CMR 420.425(A)through (E). The MassHealth agency pays for restorative services for members aged 21 and older who are not DDS clients only in accordance with the service descriptions and limitations in 130 CMR 420.425(F). The MassHealth agency considers all of the following to be components of a completed restoration and includes them in the payment for this service: tooth and soft-tissue preparation, cement bases, etching and bonding agents, pulp capping, impression, local anesthesia, and polishing. The MassHealth agency does not pay for restorations replaced within one year of the date of completion of the original restoration when replaced by the same provider. The initial payment includes all restorations replaced due to defects or failure less than one year from the original placement. (A) Amalgam Restorations. (1) The MassHealth agency does not pay for restorations attempted on primary teeth when early exfoliation (more than two-thirds of the root structure resorbed) is expected. (2) The MassHealth agency pays for only one amalgam restoration per member per tooth surface per year. Occlusal surface restorations, including all occlusal pits and fissures, are payable as a one- surface restoration whether or not the transverse ridge on an upper molar is left intact. (B) Resin-Based Composite Restorations. (1) The MassHealth agency pays for the following: (a) all resin-based composite restorations for all surfaces of anterior and posterior teeth for members under age 21 and DDS clients; (b) full-coverage composite crowns only for members under age 21, only for anterior primary teeth; and ? Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 420.000) Page 4-14 Dental Manual Transmittal Letter DEN-91 Date 10/01/13 (a) preventive resin restorations only for members under age 21, only on occlusal surfaces, and only as a single-surface posterior composite. Preventive resin restorations include instrumentation of the occlusal surfaces of grooves. (2) For anterior teeth, the MassHealth agency pays no more than the maximum allowable payment for four-or-more-surface resin-based composite restorations on the same tooth, except for reinforcing pins and commercial amalgam bonding systems. (3) The MassHealth agency pays for only one resin-based composite restoration per member per tooth surface per year. (4) The MassHealth agency does not pay more for a composite restoration on a posterior deciduous (primary) tooth than it would for an amalgam restoration. (C) Crowns, Posts and Cores and Fixed Partial Dentures (Bridgework). (1) Members Under Age 21. The MassHealth agency pays for the following: (a) crowns made from resin-based composite (indirect); (b) crowns porcelain fused to predominantly base metal, posts and cores on permanent incisors, cuspids, bicuspids, and first and second molars; and (c) prefabricated stainless-steel crowns for primary and permanent posterior teeth or prefabricated resin crowns for primary and permanent anterior teeth. Stainless-steel or prefabricated resin crowns are limited to instances where the prognosis is favorable and must not be placed on primary teeth that are mobile or show advanced resorption of roots. The MassHealth agency pays for no more than four stainless-steel or prefabricated resin crowns per member per date of service in an office setting. (2) DDS Clients Aged 21 and Older. The MassHealth agency pays for crown porcelain fused to predominantly base metal, and prefabricated posts and cores on anterior teeth only. The MassHealth agency pays for porcelain fused to predominantly base metal and stainless steel crowns for posterior teeth only if extraction (the alternative treatment) would cause undue medical risk for a member with one or more medical conditions that include, but are not limited to (a) hemophilia; (b) history of radiation therapy; (c) acquired or congenital immune disorder; (d) severe physical disabilities such as quadriplegia; (e) profound mental retardation; and (f) profound mental illness. (D) Reinforcing Pins. The MassHealth agency pays for reinforcing pins only when used in conjunction with a two-or-more-surface restoration on a permanent tooth. Commercial amalgam bonding systems are included in this category. (E) Crown Repair. The MassHealth agency pays for chairside crown repair and fixed partial denture repair. A description of the repair must be documented in the member’s dental record. The MassHealth agency pays for unspecified restoration procedures for crown repair by an outside laboratory only if the repair is extensive and cannot be done chairside. (F) Resin-Based Composite Restorations on Anterior Teeth. The MassHealth agency pays for resin-based composite restorations for one and two surfaces of anterior teeth only, for membersaged 21 and older who are not DDS clients.