Orthodontic Services — Coverage Criteria and Prior Authorization
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This document governs coverage, prior authorization, eligibility, and reimbursement rules for orthodontic services (limited, interceptive, and comprehensive) for Alaska Medicaid and Denali KidCare recipients.
No material clinical or coverage changes in this revision.
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:
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.
Complicating factors (skeletal disharmonies, space deficiency, etc.) may require future comprehensive therapy.
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.
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
| D8010 | Limited orthodontic treatment of the primary dentition |
| D8020 | Limited orthodontic treatment of the transitional dentition |
| D8030 | Limited orthodontic treatment of the adolescent dentition |
| D8050 | Interceptive orthodontic treatment of the primary dentition |
| D8060 | Interceptive orthodontic treatment of the transitional dentition |
| 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) |
Prior Authorization & Documentation Requirements
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.
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.
- Applies to second-phase transitions from limited (D8010–D8030) or interceptive (D8050–D8060) to comprehensive treatment.
Required documentation for authorization
Authorization requests must include a completed and signed Dental Service Authorization (SA) Request, a scored and signed 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 treatment plan, and other pertinent medical or dental information to support the request.
- Examples of supporting information: extractions, gingivectomy, or orthognathic surgery documentation.
- Forms are available at http://manuals.medicaidalaska.com/docs/forms.htm.
No retroactive approval
Prior authorizations will not be approved for orthodontic treatment that was rendered before the date of the prior authorization submission.
- Obtain and submit authorization before initiating any orthodontic services to avoid denial of coverage.
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
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