Section 420.424 - Service Descriptions and Limitations: Preventive Services(A)Prophylaxis. The MassHealth agency pays for prophylaxis twice per member per calendar year. The prophylaxis must include the removal of plaque, calculus, and stains from the tooth structures. MassHealth requires the provider to perform as part of this service, oral hygiene instruction including, but not limited to, proper tooth brushing and flossing instructions, and use of oral hygiene aids. The MassHealth agency does not pay a separate fee for oral hygiene instruction.(B)Fluoride. (1)Topical Fluoride Treatment. (a)Members Younger than 21 Years Old. The MassHealth agency pays for topical fluoride treatment every 90 days per member, per provider or location. Topical fluoride treatment consists of continuous topical application of an approved fluoride agent such as gels, foams, and varnishes, for a period shown to be effective for the agent. The MassHealth agency pays for treatment that incorporates fluoride with the polishing compound as part of the prophylaxis procedure. The MassHealth agency does not pay for treatment that incorporates fluoride with the polishing compound as a separate procedure.(b)Members 21 Years of Age or Older. The MassHealth agency pays for topical fluoride only for members who have medical or dental conditions that significantly interrupt the flow of saliva. Providers must submit a prior authorization request for this treatment for members 21 years of age or older.(2)Fluoride Supplements. The MassHealth agency pays for fluoride supplements only for members younger than 21 years old and through the pharmacy program (see 130 CMR 406.000: Pharmacy Services).(3)Interim Caries Arresting Medicament Application. The MassHealth agency pays for interim caries arresting medicament such as silver diamine fluoride for all MassHealth members for treatment of asymptomatic and active dental caries only, twice per tooth per lifetime. Providers are required to retain documentation demonstrating medical necessity for interim caries arresting medicament application, including documentation of asymptomatic or active dental caries.(C)Sealants. The MassHealth agency pays for sealants, for members younger than 17 years old, on the occlusal surface of permanent non-carious non-restored molars once every three calendar years per member per tooth; per provider or location. Sealants are placed on teeth by mechanically and/or chemically sealing the prepared enamel surface to prevent decay. The MassHealth agency does not pay for reapplication of sealants if the process fails within three calendar years. The MassHealth agency does not pay to replace sealants lost or damaged during the three calendar-year period when reapplied by the same provider or location. The MassHealth agency does not pay for sealants applied to any tooth that has been restored.(D)Space Maintainers. Space maintainers are indicated when there is premature loss of teeth that may lead to loss of arch integrity. The MassHealth agency pays for two space maintainers per arch per lifetime for members younger than 21 years old, to include recemented or rebonded space maintainers, and replacement space maintainers. These appliances are indicated when there is premature loss of teeth that may lead to loss of arch integrity. 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.Amended by Mass Register Issue 1342, eff. 6/30/2017.Amended by Mass Register Issue 1344, eff. 7/1/2017.Amended by Mass Register Issue 1454, eff. 10/15/2021.