CurrentAlaska MedicaidPolicy N/A

Orthodontic Services — Coverage Criteria and Prior Authorization

This document governs coverage, prior authorization, eligibility, and reimbursement rules for orthodontic services (limited, interceptive, and comprehensive) for Alaska Medicaid and Denali KidCare recipients.

Policy Summary

PayerAlaska Medicaid

PolicyOrthodontic Services — Coverage Criteria and Prior Authorization

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective DateNov 23, 2022

Next Review DateN/A

Key ActionObtain prior authorization with a completed SA Request, scored HLD report, referral oral health assessment, required imaging, and comprehensive treatment plan before initiating orthodontic services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤20Maximum recipient age

≥28HLD threshold for comprehensive

D8030 $2000Limited orthodontic max fee

D8060 $2145Interceptive max fee

Total $5,544Comprehensive total max

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Coverage and Medical Necessity Criteria

Coverage criteria

Covered when criteria specific to patient age, HLD score (for comprehensive), and required prior authorization documentation are met:

General eligibility: Recipient must be aged 20 years or younger and treatment is expected to be completed before the recipient turns 21.age <=20

If eligibility ends before treatment conclusion, remaining services are the responsibility of the recipient or parent/guardian; Alaska Medicaid will not cover remaining treatment for a recipient who is no longer eligible.

Interceptive-specific: Interceptive orthodontic treatment is limited to individuals up to 13 years of age and is reimbursed one time to include appliances and all medically necessary treatment.age <=13

Complicating factors (skeletal disharmonies, space deficiency, etc.) may require future comprehensive therapy.

Comprehensive-specific: Comprehensive orthodontic treatment requires prior authorization with a scored HLD Index Report. Routine approval requires an HLD score of 28 or greater.HLD >= 28

If HLD score is less than 28, additional medical information documenting functional impairments is required for consideration; prior authorizations will not be approved for services rendered prior to the prior authorization submission.

Prior authorization and documentation: All orthodontic services (limited, interceptive, comprehensive) require prior authorization. The authorization request must include a completed and signed Dental Service Authorization (SA) Request, a scored and signed HLD Index Report when applicable, an Orthodontic Referral Oral Health and Hygiene Assessment signed by the referring dentist, panoramic radiograph, intraoral/extraoral photos, a written comprehensive treatment plan, and other pertinent medical/dental information.

Orthodontic services are limited to recipients aged 20 years and younger. Treatment is expected to be completed before the recipient turns 21. If a recipient’s Medicaid or Denali KidCare eligibility ends before treatment is finished, Alaska Medicaid will not cover remaining services and payment becomes the responsibility of the recipient or the parent/guardian for minors. Providers may require a signed statement accepting financial responsibility when eligibility ends mid‑treatment. If treatment is discontinued for noncompliance or loss of eligibility, the orthodontist must remove brackets and provide retention as needed and must report termination to Xerox State Healthcare within 30 days.

For approval of comprehensive orthodontic treatment, the Handicapping Labiolingual Deviation (HLD) score requirement is a key determinant. A routine approval requires an HLD score of 28 or greater. If the HLD score is 28, the request is not automatically approved; the provider must submit additional medical information documenting the recipient’s functional abilities to support medical necessity.

Procedure Codes and Thresholds

Limited Orthodontic CodesCPTCovered

D8010	Limited orthodontic treatment of the primary dentition
D8020	Limited orthodontic treatment of the transitional dentition
D8030	Limited orthodontic treatment of the adolescent dentition

Interceptive Orthodontic CodesCPTCovered

D8050	Interceptive orthodontic treatment of the primary dentition
D8060	Interceptive orthodontic treatment of the transitional dentition

Comprehensive Orthodontic CodesCPTCovered

D8070	Comprehensive orthodontic treatment of the transitional dentition
D8080	Comprehensive orthodontic treatment of the adolescent dentition
D8670	Periodic orthodontic treatment visit (as part of contract)

inv-07: HLD score threshold

HLD score required for routine approvalHLD score must be 28 or greater (HLD >= 28)

When HLD < 28Additional medical information is required to determine the recipient's functional abilities

Relation to prior authorizationHLD score must be included with prior authorization request for comprehensive treatment

Prior Authorization & Documentation Requirements

Prior Authorization

Prior authorization required for all orthodontic services

All orthodontic services (limited, interceptive, comprehensive) require prior authorization. Submit a completed and signed Dental Service Authorization (SA) Request describing the condition and recommended appliance(s), a scored and signed Handicapping Labiolingual Deviation (HLD) Index Report, an Orthodontic Referral Oral Health and Hygiene Assessment signed by the referring dentist, panoramic films, intraoral and extraoral photos, a written comprehensive orthodontic treatment plan, and any other pertinent medical or dental information (e.g., extractions, gingivectomy, orthognathic surgery).

Use the official SA Request, HLD Index Report, and Orthodontic Referral Oral Health and Hygiene Assessment forms available at the Alaska Medicaid forms site.

Step Therapy

Second-phase HLD report and reimbursement offset

If a second phase is anticipated after limited or interceptive orthodontic treatment has begun, submission of a completed HLD Index Report is mandatory; when less than 18 months elapse between completion of the limited/interceptive phase and start of an approved comprehensive plan, reimbursement paid for the limited/interceptive plan will be deducted from the comprehensive plan payment.

Policy Background

Orthodontic services covered by Alaska Medicaid include limited, interceptive, and comprehensive treatments. These services address malocclusion, dentofacial deformity, and related functional and aesthetic relationships. Interceptive treatment is intended to lessen the severity or future effects of developing malformations in primary or transitional dentitions and may reduce the need for more extensive future therapy. Comprehensive treatment addresses craniofacial dysfunction and dentofacial deformity and requires prior authorization with objective scoring (HLD) to establish medical necessity.

Definitions

inv-13: Limited orthodontic treatment

DefinitionOrthodontic treatment with a limited objective not involving the entire dentition; directed at an existing problem or one aspect of a larger problem.

ScopeMay address a single aspect of malocclusion; does not encompass treatment of the entire dentition.

IntentProvide a one-time, focused intervention when comprehensive therapy is deferred or not indicated.

inv-14: Interceptive orthodontic treatment

DefinitionTreatment to lessen the severity or future effects of a malformation and to eliminate its cause; may include localized tooth movement and redirection of ectopically erupting teeth.

Age limitationLimited to individuals up to 13 years of age.