Date of Adoption: March 20, 2001.

Purpose: To clarify that Medicaid does not cover laboratory-processed, or specially fitted, crowns for posterior teeth. The department also rewrote for clarity other policies regarding crowns, including coverage, prior authorization requirements, and what is included in the reimbursement for crowns.

Citation of Existing Rules Affected by this Order: Amending WAC 388-535-1230 Crowns.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520.

Adopted under notice filed as WSR 01-03-154 on January 24, 2001.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

March 20, 2001

Bonita H. Jacques, Chief

Office of Legal Affairs

(a) Stainless steel, and

(b) Nonlaboratory resin for primary anterior teeth.

(2) MAA does not cover laboratory-processed crowns for posterior teeth.

(3) MAA requires prior authorization for the following crowns, which are limited to single restorations for permanent anterior (upper and lower) teeth(( and require prior authorization by MAA)):

(a) Porcelain fused to a high noble metal;

(b) Porcelain fused to a predominately base metal;

(c) Porcelain fused to a noble metal;

(d) Porcelain with ceramic substrate;

(e) Full cast high noble metal;

(f) Full cast predominately base metal;

(g) Full cast noble metal; and

(h) Resin (laboratory).

(((3))) (4) Criteria for covered crowns as described in subsections (1) and (3) of this section:

(a) Crowns may be authorized when the ((tooth meets the criteria of)) crown is dentally necessary.

(b) Coverage is based upon a supportable five year prognosis that the client will retain the tooth if the tooth is crowned. The provider must submit the following client information:

(i) The overall condition of the mouth;

(ii) Oral health status;

(iii) Patient maintenance of good oral health status;

(iv) Arch integrity; and

(v) Prognosis of remaining teeth (that is, no more involved than periodontal case type II).

(c) Anterior teeth must show traumatic or pathological destruction to loss of at least one incisal angle.

(((4))) (5) The laboratory processed crowns described in subsection (((2))) (3) are covered:

(a) ((Are covered)) Only when a lesser service will not suffice because of extensive coronal destruction, and treatment is beyond intracoronal restoration;

(b) Only once per permanent tooth in a five year period;

(((b) Are covered))

(c) For endodontically treated anterior teeth only after satisfactory completion of the root canal therapy. Post-endodontic treatment X-rays must be submitted for prior authorization of these crowns((; and

(c) Including tooth and soft tissue preparation, amalgam or acrylic build-ups, temporary restoration, cement base, insulating bases, impressions, and local anesthesia; and

(d) Are covered when a lesser service will not suffice because of extensive coronal destruction, and treatment is beyond intracoronal restoration)).

(6) MAA reimburses only for covered crowns as described in subsections (1) and (3) of this section. The reimbursement is full payment; all of the following are included in the reimbursement and must not be billed separately:

(a) Tooth and soft tissue preparation;

(b) Amalgam or acrylic build-ups;

(c) Temporary restoration;

(d) Cement bases;

(e) Insulating bases;

(f) Impressions;

(g) Seating; and

(h) Local anesthesia.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, 388-535-1230, filed 3/10/99, effective 4/10/99.]

Washington State Code Reviser's Office