Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-75 - Dental services

Current through June, 2024
(a) Dental services
				  means diagnostic, preventive, and corrective procedures administered because of
				  a diseased condition, injury, or impairment, by or under the supervision of a
				  dentist licensed under state law for the treatment of teeth and the associated
				  structures of the oral cavity.
(b)
				  Dental services for individuals under the age of twenty-one are limited to the
				  following services:
(1) Emergency treatment
				  which includes services to relieve dental pain, eliminate infection, and
				  treatment of acute injuries to the teeth and supporting structures of the
				  oro-facial complex;
(2) X-ray with
				  the limitations of one set of two bitewing rediographs during a twelve-month
				  period and one set of full month rediographs during a five-year period,
				  including bitewings;
(3) Preventive
				  dental services:
(A) Topical application of
				  fluoride;
(B) Sealants for occlusal
				  surface of permanent molar teeth only for children ages six through fifteen;
				  and
(C) Dental examination and
				  prophylaxis treatment, which shall be limited to not more than once every six
				  months, and which shall not cover routine examination of institutional
				  patients;
(4)
				  Periodontic treatment limited to cases of medical necessity, includes in the
				  procedure, post operative care for six months following treatment and recall
				  treatment limited to three times a year. Prior authorization and a medical
				  report is required: Osseous and mucogingival surgeries, grafts, and implants
				  are considered elective and are not covered;
(5) Dental work done under conscious sedation
				  (inhalation or intravenous) or general anesthesia shall be allowed only in
				  cases of medical necessity and within program policy guidelines. A medical
				  report is required;
(6) Root canal
				  therapy with the following requirements:
(A)
				  Root canal therapy shall be covered for a maximum of once per tooth, except in
				  cases of poor prognosis, as in the case of advanced decay or bone loss or prior
				  root canal failure. Completed root canal x-rays shall be submitted with the
				  claim for payment;
(B) Root canal
				  therapy shall not be covered for the purpose of overdenture fabrication except
				  under special medical circumstances which requires prior authorization and a
				  medical report;
(7)
				  Extraction, whether done in the dentist's office or in a hospital under general
				  anesthesia;
(8) Restorative
				  dentistry with the following limitations:
(A)
				  Restorative dentistry shall be limited to the use of amalgam, silicate, resin,
				  plastic, acrylic, or composite fillings;
(B) Non-duplicated restorative procedures are
				  allowed only once per tooth every two years as needed in the treatment of
				  fractured or carious teeth;
(C)
				  Acrylic jackets and acrylic veneer crowns, if authorized, shall be limited to
				  anterior teeth for a maximum of once per tooth;
(D) The department shall not allow a separate
				  charge for tooth preparation, temporary restorations, pulp caps, cement bases,
				  impressions, or local anesthesia;
(E) An amalgam or composite buildup shall be
				  considered a component part of the preparation for the completed restoration
				  except in special circumstances, and by report; and
(F) Amalgam restorations are allowed, but
				  composite resin or acrylic restorations in posterior secondary teeth (except
				  the facial surface of permanent first premolars) shall be considered purely
				  cosmetic dentistry and shall not be covered;
(9) Drugs administered by the dentist in the
				  dentist's office shall be covered at the rate of fifty cents for each drug plus
				  the cost of the drug;
(10) Dental
				  prosthesis limited to crowns, space maintainers, partial or full dentures,
				  adjustments and repair, subject to the following limitations:
(A) Partial dentures shall be limited to fill
				  the space due to the loss of one or more anterior teeth and to fill the space
				  due to the loss of two or more posterior teeth exclusive of third
				  molars;
(B) One partial or full
				  denture shall be allowed per arch per recipient in any five year period. This
				  is allowed when existing dentures cannot be repaired or adjusted;
(C) Temporary partial dentures shall be
				  allowed only when teeth have been extracted recently and shall be subject to
				  the maximum benefits for dentures;
(D) Denture relines are limited to one per
				  denture every two years;
(E)
				  Precious, semi-precious, and non-precious metal cast crowns shall be limited to
				  permanent first and second molars;
(F) Overdentures shall not be covered;
				  and
(G) Space maintainers are
				  limited to children age fourteen and under to hold the space for the eruption
				  of the permanent cuspids, pre-molars or first molars due to premature loss of
				  the deciduous predecessor; and
(11) Consultation and dental surgery with the
				  following limitations:
(A) Routine
				  postoperative visits shall be considered part of the total surgical procedure
				  and shall not be separately compensable; and
(B) Vestibuloplastys, skin grafts, bone
				  grafts, and implants shall not be covered except when one or more is part of
				  the treatment for fractured jaws.