Section 4 / Part 7
Effective Date: April 10, 2006

Dental services

Dental services are provided when the condition of the teeth and gums constitutes or contributes to a physical or mental disability which creates an impediment to employment. Dental services may be needed because of other disabilities which contribute to dental problems.

A program of general dental care is not allowed.

During the rehabilitation process a client may require preventive dental work such as filling of teeth. The intercurrent illness authority (including the cost cap) may be used for treatment of such acute dental problems which prevent continuation of the rehabilitation plan.

Some issues to consider when determining whether or not to provide dental services are:

• Many dental procedures can be successfully completed at different levels of care.
• Many dental procedures require specific, sometimes long term, follow-up care. Counselors and clients should know the extent of services necessary to bring about a desired outcome before beginning the process.
• Some dental procedures are temporary in nature and will require additional work in the future.
• Many dental procedures require the client to maintain a regimen of personal oral hygiene.
• When authorizing such services, the counselor should assure that the client understands the need to maintain adequate oral hygiene. It may be necessary to provide education on oral hygiene and the consequences of neglect, as well as assistance in developing the proper hygiene regimen, especially for clients who have a history of poor dental hygiene. One option for provision of such education is referral to an oral hygienist.

Dental services may be paid up to the usual and customary rate less 10%. This RS rate is subject to future change based on analysis of typical fees and usage. The appropriate CPT and service codes for dental procedures are required, just as with medical services.

The counselor may authorize fees above this rate if the total cost would be less expensive than the RS rates plus travel expenses to another community. In these situations, the cost savings must be noted in the narrative.

When dentists are not willing to provide services at the RS rate, an exception request must be approved. Each RS Program Administrator will establish a procedure for routing such exception requests through the RS Managers, RS Program Administrator or both. Use of the Exceptions Request Form (see Section 8 / Part 54) is required.

Special procedures for dental surgery:

• The surgery analysis described above is required for oral and maxillofacial surgeries with American Dental Association (ADA) procedure codes D7260 to D7999.
• The surgery analysis is NOT required for ADA procedure codes D7000 to D7259. Therefore, most extractions will not require completion of the surgery analysis.
• The Counselor must get the ADA code from the dentist prior to authorizing the service in order to determine whether the surgery analysis is required.
• See Section 9 / Part 29 for a copy of the ADA code listing.