Section He-W 566.04 - Covered Services(a) The following dental services shall be covered for recipients who are under 21 years of age: (1) Prophylaxis, no more frequently than every 150 days;(2) Restorative treatment;(3) Periodic examinations, no more frequently than every 150 days, unless they are medically necessary to diagnose an illness or condition;(4) Vital pulpotomy, which consists of removal of diseased or involved pulp in an effort to retain the remaining pulp in a healthy, vital condition;(5) Extractions of symptomatic teeth associated with diagnosed pathology, such as tumor, cyst, or infection, except third molars as described in (7) below;(6) Extractions of asymptomatic teeth, except third molars as described in (7) below, subject to prior authorization in accordance with He-W 566.07, as follows: a. When associated with diagnosed pathology, such as tumor, cyst, or infection; orb. When extraction is part of an orthodontic treatment plan that has been approved through prior authorization by the department in accordance with He-W 566.07;(7) Third molar extraction, subject to prior authorization in accordance with He-W 566.07;(8) General anesthesia when medically necessary and documented in the recipient's dental records;(9) Nitrous oxide analgesia and intravenous therapy sedation;(10) Comprehensive orthodontic treatment for severe handicapping malocclusion in accordance with He-W 566.05(a), subject to prior authorization in accordance with He-W 566.07;(11) Interceptive orthodontic treatment in accordance with He-W 566.05(b), subject to prior authorization in accordance with He-W 566.07;(12) Space maintainers when medically necessary to replace a prematurely lost deciduous or permanent molar or bicuspid;(13) Limited orthodontic treatment in accordance with He-W 566.05(c);(14) Radiographs as follows: a. Complete series or panographic survey, once every 5 years;b. Bitewings every 12 months if medically necessary; andc. All types of dental radiographs regardless of limits in a. and b. above, as may be required to complete a differential diagnosis;(15) Palliative treatment when the claim is submitted in accordance with He-W 566.10(f);(16) Removable prosthetic replacement of permanent teeth subject to prior authorization in accordance with He-W 566.07;(17) Topical fluoride treatment applied twice per year until age 21;(18) If moderate or high risk of caries is documented, 2 applications of silver diamine per tooth, provided that no more than 18 total silver diamine treatments shall be administered per year and no application of silver diamine shall be administered after the recipient reaches the age of 21;(19) Endodontia, including root canal therapy, excluding third molars, when the claim is accompanied by a radiograph, and the endodontia treatment is deemed complete when all radiographs demonstrate that the canals are completely filled to the apex of the root(s) of the tooth in accordance with He-W 566.10(e);(21) Periodontal treatment limited to prophylaxis, scaling, and root planing;(22) Surgical periodontal treatment subject to prior authorization in accordance with He-W 566.07;(23) Sealants for permanent and deciduous molars every 5 years, until age 21;(24) Diagnostic and preventive dental services, with the exception of orthodontic treatment as allowed in (b) below, available for EPSDT-eligible children in accordance with He-W 546.05; and(25) Other services determined by the department to be medically necessary, in accordance with He-W 546.06.(b) Orthodontic treatment for malocclusions that do not meet the criteria set forth in He-W 566.05(b) shall be considered for orthodontic treatment under the EPSDT prior authorization for coverage based on medical necessity provisions at He-W 546 when documentation of the following is submitted to the department: (2) Prognosis with and without treatment;(3) Date of onset of the illness or condition and etiology, if known;(4) Clinical significance or functional impairment or pathology caused by the illness or condition resulting from the malocclusion;(5) Demonstration of evidence of the degree to which the malocclusion contributes to the illness or condition;(6) Specific types of services to be rendered by each discipline associated with the total treatment plan;(7) Therapeutic goals to be achieved by each discipline and anticipated time for achievement of goals;(8) Explanation of any existing conditions that are likely to limit efficacy of treatment;(9) Extent to which health care services have been previously provided to address the illness or condition and summary of results demonstrated by prior care;(10) Orthodontic records as described in He-W 566.05(g)(1), (2) and (4); and(11) Any additional documentation in accordance with He-W 546.06(b) or any other documentation available which might assist in making a determination of medical necessity of the proposed orthodontic treatment.(c) The documentation submitted in accordance with (b) above shall be completed by health professionals who are sufficiently trained and duly licensed to diagnose and treat the illness or condition arising from the malocclusion and creating the medical necessity for treatment. (d) The documentation described in (b) and (c) above shall be submitted to the department by the medicaid enrolled provider who will complete the orthodontic treatment along with a request for prior authorization in accordance with He-W 546.06.(e) The following dental services shall be covered for recipients 21 years of age or over for relief of acute pain or elimination of acute infection or diagnosed pathology: (1) Palliative treatment when the claim is submitted in accordance with He-W 566.10(f);(2) Extraction of the causative tooth or teeth and biopsy of the tooth or teeth;(3) Treatment of severe trauma, when a determination is made by the attending clinician using standard medical parameters for emergency conditions, which shall include, but not be limited to:b. Laceration requiring suturing;c. Abrasion requiring debridement; ord. Bone fracture requiring reduction; and(4) Radiographs and examinations as necessary to assess conditions described in (1)-(3) above.N.H. Admin. Code § He-W 566.04
(See Revision Note at chapter heading He-W 500); ss by #5639, eff 6-17-93; ss by #7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by #9902, eff 6-1-11
Amended by Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12782, Effective 5/21/2019, Expires 11/18/2019.Amended by Volume XL Number 2, Filed January 9, 2020, Proposed by #12937, Effective 12/7/2019, Expires 12/7/2029.