Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 3 - Dental Services › 7 AAC 110.150 - Dental services for recipients under 21 years of age

Current through May 31, 2024
(a) Except as
				  provided in
				  7 AAC 110.200(3), the department will pay
				  for the services identified in the
Fee Schedule: Dental Services for
				  Children
, adopted by reference in
				  7 AAC 160.900, as follows, provided to a recipient under 21
				  years of age:
(1) periodic oral evaluation
				  not more than two times per calendar year, limited oral evaluation not more
				  than two times per calendar year, and comprehensive oral evaluation not more
				  than two times per calendar year; panoramic radiographs not more than one time
				  per calendar year and other dental radiographs as necessary for dental
				  care;
(2) preventive care, as
				  follows:
(A) prophylaxis, limited to
				  necessary scaling, polishing, and instructions on oral hygiene and diet, not
				  more than two times per calendar year;
(B) topical application of fluoride not more than four times per
				  calendar year, or topical fluoride varnish not more than four times per
				  calendar year, or a combination of topical application of fluoride and fluoride
				  varnish not more than four times per calendar year;
(C) sealants, limited to one time per tooth
				  per calendar year; and
(D) space
				  management therapy restricted to posterior teeth; the department will pay for a
				  primary teeth space maintainer only if a significant risk exists of detrimental
				  drifting occurring before the permanent tooth erupts and for a permanent teeth
				  space maintainer only if prosthodontic treatment is not
				  applicable;
(3)
				  restorative care for the treatment of decayed or fractured teeth, including
				  amalgams and resins, and crowns if the tooth cannot be restored with amalgams
				  or resin; under this paragraph,
(A) a claim
				  submitted for up to two crowns in a single day must be accompanied by medical
				  justification;
(B) a provider must
				  obtain prior authorization from the department for three or more crowns in a
				  single day or four or more crowns in a 12-month period;
(C) all surfaces restored on a single tooth
				  on the same day are considered connected; therefore, payment is limited to one
				  single or multi surface restoration code per tooth per day;
(D) final restorations are limited to not
				  more than five surfaces per tooth; tooth preparation, temporary restorations,
				  sedative and cement bases, and local anesthesia are considered components of a
				  complete restorative procedure and may not be billed separately; and
(E) the department will provide payment for
				  a crown only upon seatment of the permanent crown, and for a partial or denture
				  only upon seatment of the appliance; the department will not provide partial
				  payment for incomplete or in-progress dental services;
(4) endodontics, with the following
				  limitations:
(A) palliative and sedative
				  treatments may not exceed two times per tooth before a definitive
				  treatment;
(B) with respect to
				  root canal therapy, tooth preparation, filling of the root canal, and follow-up
				  are considered components of a complete root canal and may not be billed
				  separately; and
(C) a separate
				  claim may be made for pin retention and restoration, and may not exceed five
				  surfaces per tooth;
(5)
				  periodontics, including treatment of pain or acute infection of supporting
				  tissues of the teeth, including gingivitis, periodontitis, and periodontal
				  abscess;
(6) prosthodontics,
				  including replacement of a complete or partial denture only if the existing
				  denture is unusable and only once per five calendar years;
(7) oral surgery; under this paragraph, the
				  following services are covered:
(A)
				  extractions; under this subparagraph,
(i) a
				  claim submitted for up to two extractions in a single day to alleviate
				  immediate pain or infection must be accompanied by medical
				  justification;
(ii) a provider
				  must obtain prior authorization from the department for three or more
				  extractions in a single day or four or more extractions in a 12-month period to
				  alleviate immediate pain or infection; and
(iii) a provider must obtain prior authorization from the
				  department for an extraction that is required for a reason other than to
				  alleviate immediate pain or infection;
(B) local anesthesia, materials, and routine
				  postoperative care are considered components of a complete surgical procedure
				  and may not be billed separately;
(8) anesthesia and sedation in accordance with
				  7 AAC 110.155 and necessary for dental services covered
				  under this section;
(9)
				  professional consultation, if medically necessary or if requested by the
				  department.