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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Comprehensive Dental Benefit (IB 25-6)

Date: 03/04/25

Louisiana Healthcare Connections is sharing with providers an update to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Comprehensive Dental Benefit (IB 25-6).

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a comprehensive benefit program for Medicaid eligible individuals under the age of 21. Federal law, 42 CFR Part 441 Subpart B, mandates EPSDT-eligible beneficiaries are eligible to receive all medically necessary health care, screening, diagnostic services, treatment, and other measures to correct or improve physical or mental conditions (section 1905(r) of the Social Security Act).

Unless prohibited or excluded, services may include those not otherwise covered by the Louisiana Medicaid State Plan or explicitly described in Dental Benefit Program Manager (DBPM) contracts. These regulations include dental care, at the earliest age necessary, needed for:

  • relief of pain
  • infections
  • restoration of teeth
  • maintenance of dental health 
  • emergency care 
  • preventative care, and 
  • therapeutic care.

This also includes dental services that are provided for care of dental diseases, which, if left untreated, may become acute dental problems or may cause irreversible damage to teeth or supporting structures.

The following definition provides criteria for medically necessary service determination:

Medically Necessary Service(s) are those that are in accordance with generally accepted, evidence-based medical standards or are considered by most physicians (or other independent licensed practitioners) within the community of their respective professional organizations to be the standard of care. In order to be considered medically necessary, services must be: (1) deemed reasonably necessary to diagnose, correct, cure, alleviate or prevent the worsening of a condition or conditions that endanger life, cause suffering or pain or have resulted or will result in a handicap, physical deformity or malfunction; and (2) those for which no equally effective, more conservative and less costly course of treatment is available or suitable for the Beneficiary. Any such services must be individualized, specific and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and neither more nor less than what the Beneficiary requires at that specific point in time. Although a service may be deemed medically necessary, it doesn’t mean the service will be covered under the Louisiana Medicaid Program. Services that are experimental, non-Food and Drug Administration (FDA) approved, investigational, or cosmetic are specifically excluded from Medicaid coverage are deemed “not medically necessary.”

Dental Benefit Program Managers (DBPM) are to educate providers and enrollees on EPSDT provisions and to make determination as to whether services are medically necessary. Approved medically necessary determinations for services not listed on the EPSDT fee schedule will require manual pricing and/or negotiation of rates with the servicing provider.

Questions related to this bulletin should be directed to MedicaidDental@la.gov.