Wisconsin Legislature: DHS 107.07(2)(a)4.

Alert! This chapter may be affected by an emergency rule:

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(f) Removable prosthodontic services.

(g) Fixed prosthodontic services.

(h) Oral and maxillofacial surgery services.

(j) All of the following other services:

1. Unclassified treatment.

2. Palliative emergency treatment.

3. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation.

4. Hospital calls.

Note: Orthodontia may be covered under early and periodic screening, diagnosis and treatment (EPSDT) services. Please see s. DHS 107.22 (4).

(1m) Covered services; dental hygienists. Except as provided under subs. (2), (3), (4), and (4m), all of the following dental services are covered services when provided by a dental hygienist who is individually certified under ch. DHS 105 within the scope of dental hygiene as defined in s. 447.01 (3), Stats.:

(a) Oral screening and preliminary examination.

(b) Prophylaxis.

(d) Pit and fissure sealants.

(e) Scaling and root planing.

(f) Full mouth debridement.

(g) Periodontal maintenance.

(2) Services requiring prior authorization.

(a) All of the following dental services require prior authorization in order to be reimbursed under MA:

1. Molar root canal therapy for recipients ages 21 and over.

2. All of the following periodontal services:

a. Grafts, mucogingival and osseous surgical periodontal services.

b. Provisional splinting.

c. Gingivectomy and gingivoplasty.

d. Scaling and root planing.

e. Periodontal maintenance.

3. All of the following removable prosthodontic services:

a. Complete dentures.

b. Partial dentures.

4. All of the following oral and maxillofacial surgery services:

a. Surgical extractions of teeth and tooth roots for orthodontia, or for asymptomatic impacted teeth.

b. Temporomandibular joint surgery.

c. Repairs of orthognathic deformities.

d. Other repair procedures including osteoplasty, alveoloplasty, and sialolithotomy.

6. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation for recipients age 21 and over, where the treatment is not provided in a hospital or in an emergency situation.

7. Surgical or other dental services, including fixed prosthodontics in order to correct conditions that may reasonably be assumed to significantly interfere with a recipient’s personal or social adjustment or employability.

(b) A provider who submits a request for prior authorization of dental services to the department shall identify the recipient’s birth date and the items enumerated in s. DHS 107.02 (3) (d).

(3) Other limitations. All of the following limitations apply to the coverage of dental services under this section:

(a) General limitations. The MA program may impose reasonable limitations on reimbursement of the services listed in subs. (1) and (1m) regarding any of the following:

1. Frequency of service per time period, including coverage of services in emergency situations only.

2. Allowable age of recipient who may receive a service.

3. Required documentation, including pathology report or operative report.

(b) Specific limitations.

1. Reimbursement for dentures and partial dentures includes 6 months postdelivery care. If a prior authorization request for these services is approved, the recipient shall be eligible on the date the authorized treatment is started, which is the date the final impressions were taken. Once started, the service shall be reimbursed to completion, regardless of the recipient’s eligibility.

2. Temporomandibular joint surgery is a covered service only when performed after all professionally accepted non-surgical medical or dental treatment has been provided, and the necessary non-surgical medical or dental treatment has been determined unsuccessful by the department’s dental consultant.

3. The diagnostic work-up for orthodontic services shall be performed and submitted with the prior authorization request. If the request is approved, the recipient is required to be eligible on the date the authorized orthodontic treatment is started as demonstrated by the placement of bands for comprehensive orthodontia. Once started, the service shall be reimbursed to completion, regardless of the recipient’s eligibility.

4. A non-covered service specified under sub. (4) or (4m) may be reimbursed if the department’s dental consultant requests that the service be performed in order to review the request for prior authorization.

(4) Non-covered services; dentists and physicians. The following dental services are not covered under MA whether or not the service is performed by a dentist; physician; or a person under the supervision of a dentist or physician:

(a) General services for purely aesthetic or cosmetic purposes.

(d) Tests and laboratory examinations, other than for diagnostic casts when required by the department.

(e) Oral hygiene instruction or training in preventive dental care as a separate procedure, including tooth brushing technique, flossing or use of special oral hygiene aids, tobacco cessation counseling, or nutritional counseling.

(f) The following restorative services:

1. Labial veneer.

2. Temporary crowns.

3. Cement bases as a separate item.

4. Endodontic filling materials that are not approved for use by the American Dental Association.

(g) Pulp cappings.

(h) The following removable prosthodontic services:

1. Overlay dentures.

2. Overlay partial dentures.

3. Duplicate dentures and adjustments.

(i) The following implant services:

1. Tooth implants.

2. Transplantations.

3. Surgical repositioning except reimplantation under sub. (3).

4. Transseptal fiberotomies.

(j) Orthodontic services.

(k) The following adjunctive general services:

2. Non-surgical treatment of temporomandibular joint disorder.

3. Behavior management.

4. Athletic mouthguards.

5. Local anesthesia as a separate procedure.

6. Occlusal guard, analysis and adjustment.

7. Non-covered services that are listed in s. DHS 107.03.

(L) Professional visits, other than for the oral evaluation of a nursing home resident, or hospital calls as noted in sub. (1) (j) 4.

(4m) Non-covered services; dental hygienists. The following services are not covered by MA whether or not the service is performed by a person under the supervision of a dentist or physician or by a dental hygienist who is individually certified under ch. DHS 105:

(a) Services performed outside the scope of practice of dental hygiene as defined under ss. 447.01 (3) and 447.06, Stats.

(b) Oral hygiene instruction or training in preventive dental care as a separate procedure, including tooth brushing technique, flossing or use of special oral hygiene aids, tobacco cessation counseling, or nutritional counseling.

(5) Unusual circumstances. In certain unusual circumstances the department may request that a non-covered service be performed, including but not limited to diagnostic casts, in order to substantiate a prior authorization request. In these cases the service shall be reimbursed.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (c) 10. and (2) (c) 9. e. and f., cr. (2) (c) 9. g. and (3) (8), r. and recr. (4) (q), Register, February, 1988, No. 386, eff. 3-1-88; r. and recr. (1) (g) and (4) (j), renum. (2) (c) 9. to 12. and (4) (k) to (t) to be (2) (c) 10. to 13. and (4) (m) to (v), cr. (2) (c) 9., (4) (k) and (L), Register, December, 1989, No. 408, eff. 1-1-90; correction in (4) (j) made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1989, No. 408; CR 05-033: r. and recr. (1), (3) and (4) cr. (1m), (2) (a) 5. to 7. and (4m), am. (2) (a) (intro.) and 1. to 4. and (2) (b), r. (2) (c) Register August 2006 No. 608, eff. 9-1-06; emerg. r. (1) (k) and (2) (a) 5., am. (2) (a) (intro.), (3) (intro.), (a) 3., (4) (intro.), (j) and (4m) eff. 4-30-07; CR 07-041: r. (1) (i), (k) and (2) (a) 5., am. (2) (a) (intro.), (3) (intro.), (a) 3., (4) (intro.), (j) and (4m) Register December 2007 No. 624, eff. 1-1-08; corrections in (1m) (intro.) and (4m) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 22-043: r. (4) (b), am. (4) (c), r. (4) (k) 1. Register May 2023 No. 809, eff. 6-1-23.

DHS 107.08 Hospital services.

(1) Covered services.

(a) Inpatient services. Covered hospital inpatient services are those medically necessary services which require an inpatient stay ordinarily furnished by a hospital for the care and treatment of inpatients, and which are provided under the direction of a physician or dentist in an institution certified under s. DHS 105.07 or 105.21.

(b) Outpatient services. Covered hospital outpatient services are those medically necessary preventive, diagnostic, rehabilitative or palliative items or services provided by a hospital certified under s. DHS 105.07 or 105.21 and performed by or under the direction of a physician or dentist for a recipient who is not a hospital inpatient.

(2) Services requiring prior authorization. The following covered services require prior authorization:

(a) Covered hospital services if provided out-of-state under non-emergency circumstances by non-border status providers;

(b) Hospitalization for non-emergency dental services; and