Orthodontia Review Policy and Procedure — Texas Children's Medicaid/CHIP
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Governs determination, prior authorization, documentation, provider qualifications, and coverage levels for medically necessary orthodontic services for Texas Medicaid and CHIP pediatric members (including certain pre/post surgical cases). Applies to providers seeking reimbursement through DentaQuest Dental for these programs.
No material clinical or coverage changes in this revision.
Coverage Criteria and Medical Necessity
Level I–IV Medical Necessity Criteria
Covered when the Member meets the specific Level criteria and documentation supports severe handicapping malocclusion or a qualifying special medical condition (e.g., cleft palate, post‑head trauma involving the oral cavity, skeletal anomalies). CHIP covers pre‑ and post‑surgical orthodontia related to cleft palate, oral trauma, or skeletal anomalies.
Providers may submit specified procedure codes; exceptions for migrant farm worker children or foster care delays.
Providers must use appropriate banding procedure code; interceptive orthodontic treatment is not allowed when comprehensive treatment is indicated unless extenuating circumstances are documented.
Providers may prior authorize additional services for medically necessary extenuating circumstances; documentation requirements (radiographs, photos, treatment plan) apply.
Pre‑ and post‑orthodontic procedures in conjunction with orthognathic surgery required; exceptions for migrant/foster care delays.
Additional Services / Exceptions
Exceptions and additional services may be prior authorized when medically necessary or when extenuating circumstances exist; each request is reviewed case‑by‑case.
Documentation and prior authorization required (radiographs, photographs, treatment plan, ADA claim form per requirements).
Premature Termination and Additional Services
Premature termination is considered part of comprehensive services when properly documented and prior authorized; re‑initiation eligibility depends on the documented reason for removal.
Failure to submit required release and documentation will prevent authorization.
Reimbursement Criteria
Payment for an orthodontic treatment episode is tied to prior authorization and specific billing rules for the initial, monthly, and final payments.
Initial banding payment includes the initial workup.
If requesting additional monthly adjustments, include code D8670 on the prior authorization per documentation requirements.
Providers must follow prior authorization submission and documentation rules to obtain final payment.
Interceptive orthodontic treatment is not covered in conjunction with comprehensive orthodontic treatment. In addition, interceptive treatment is not allowed when comprehensive treatment is indicated unless extenuating circumstances are documented. Providers must use the appropriate procedure code applicable for banding and follow the Level-specific completion timelines when submitting prior authorization requests.
Orthodontic services performed solely for cosmetic purposes are not a benefit of Texas Medicaid and will not be authorized or reimbursed. Requests should document medical necessity; services that are medically necessary due to cleft palate, craniofacial conditions, or head trauma may be prior authorized and reviewed on a case-by-case basis.
Continuation of a case that began through a private arrangement may be considered for prior authorization only if the Member began treatment prior to becoming Medicaid eligible. Continuation requests will be denied if the Member began treatment while already Medicaid eligible. For consideration, submit a completed Orthodontic Continuation of Care Form, a 2012-or-later ADA claim form listing services to be rendered, a copy of any prior approval with total approved case fee and payment structure, detailed payment history, original study models (if available), and panorex film as applicable.
There will be no payment for denied cases. Payment for authorized banding includes the initial workup, and providers should ensure all required documentation is submitted with the prior authorization to avoid denials. Study models submitted with a request will not be returned unless a self‑addressed, postage‑paid box is included.
Procedure Codes, Thresholds, and Code-specific Rules
| D8010 | Limited orthodontic treatment of the primary dentition. |
| D8020 | Limited orthodontic treatment the transitional dentition. |
| D8210 | Removable appliance therapy. |
| D8220 | Fixed appliance therapy. |
| 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. |
| D8090 | Comprehensive orthodontic treatment of the adult dentition. |
| D8670 | Periodic orthodontic treatment visit (monthly adjustments). |
| D8670 | Monthly adjustment |
| D8680 | Orthodontic retention (final payment when treatment is complete) / prior authorized procedure code for completion |
| Procedure Code, 1 | Orthodontic Retention (removal of appliances, construction and placement of retainer(s)) — used for premature debanding |
Prior Authorization, Documentation, and Provider Responsibilities
Obtain prior authorization for all orthodontic episodes and changes
Prior authorization is required for initiation of orthodontic services, requests for additional monthly adjustments (use D8670), completion (final payment) requests, transfers, premature termination, and continuation of care; submit required documentation with each request.
- Initiation, additional monthly adjustments (bill D8670), completion (final payment), transfers, premature termination and continuation all require prior authorization.
- Providers must use the appropriate procedure code applicable for banding and for final payment as prior authorized.
Prior authorize premature debanding with signed release
Premature removal (debanding) of orthodontic appliances must be prior authorized and accompanied by a signed release form plus a completed prior authorization request documenting the reason for removal.
- Signed release from parent/legal guardian or Member (if ≥18 or emancipated) must be submitted.
- Prior authorization request must document uncooperative/non‑compliant behavior, member‑requested removal, or extenuating circumstances (e.g., incarceration, mental health with physician recommendation, foster care placement, child of a migrant farm worker).
Bill prior‑authorized codes for initial, monthly, and final payments
Bill only the procedure codes that were prior authorized for initial and final payments; use D8670 for monthly adjustment visits and bill the prior‑authorized procedure code for the final payment (e.g., D8680 when treatment is complete).
- Initial payment billed when bands are placed using the prior authorized procedure code.
- Monthly adjustments must be billed with D8670; total allowed varies by service level.
- Final payment billed using the prior authorized procedure code (D8680 for completion).
Do not provide interceptive treatment alongside comprehensive cases without authorization
Do not submit interceptive orthodontic treatment when comprehensive treatment is indicated; interceptive therapy is not covered in conjunction with comprehensive treatment unless extenuating circumstances are documented and prior authorized.
- Interceptive orthodontic treatment is not allowed when comprehensive orthodontic treatment is indicated unless extenuating circumstances are documented.
- Providers may prior authorize additional services for extenuating circumstances on a case‑by‑case basis.
Follow provider qualifications, coding, and transfer directives
Providers must maintain required qualifications and follow provider directives in the policy (including use of appropriate procedure codes for banding and premature debanding) and follow instructions for transfers, continuation, and completion.
- Use the appropriate procedure code applicable for banding and for premature debanding per policy.
- New providers completing transferred cases must request a new prior authorization.
- Ensure documentation and records meet policy requirements at completion and termination.
Include ADA claim form, models/photos, radiographs and treatment plan with prior authorization
Submit the ADA 2012 (or newer) claim form listing service codes plus duplicate diagnostic models or a complete set of diagnostic photographs, radiographs, cephalometric x‑ray with tracings, and the treatment plan with all prior authorization requests.
- Include ADA 2012+ claim form with service codes noted.
- Attach duplicate diagnostic models or complete diagnostic photographs, radiographs, cephalometric x‑ray with tracings, and the treatment plan.
- For CHIP members, include copy of medical prior authorization approval letter for surgery when applicable.
Provide panorex, photos, and signed completion statement for final payment
Completion (final payment) prior authorization must include a post‑treatment panorex film, photographs, and a signed statement from the treating provider confirming treatment completion.
- Post‑treatment panorex film.
- Photographs demonstrating completed treatment.
- Signed provider statement indicating treatment is complete.
Submit full original documentation, reason for transfer, and treatment narrative for transfers/continuations
For transfers or continuation of care, submit all original required documentation plus the reason for transfer and a narrative of the current treatment status; new provider must obtain records and request a new prior authorization.
- All documentation required for an original prior authorization (models/photos, radiographs, cephalogram, treatment plan).
- Reason the member left the previous provider and narrative noting treatment status.
- Completed Orthodontic Continuation of Care Form, ADA claim form listing services, prior approvals and payment history, study models and panorex as applicable.
Submit signed release plus completed prior authorization for premature termination
For premature termination cases, submit a signed release form and a completed prior authorization request documenting the reason for termination (member request, non‑compliance, or qualifying extenuating circumstances).
- Signed release form from parent/legal guardian or Member (if ≥18 or emancipated).
- Completed prior authorization request with documentation of the specific reason (uncooperative/non‑compliant, member requested removal, or extenuating circumstances).
Remove appliances and deliver final records and x‑rays at termination
At termination, the requesting provider is responsible for removal of appliances and delivery of final records, including final x‑rays and study models as required.
- Remove brackets, arch wires and other appliances and fabricate/deliver retainers as applicable.
- Provide final records and x‑rays at the time of termination; new provider must obtain records for transfers.
Comply with Texas State Board of Dental Examiners documentation and qualification rules
Comply with Texas State Board of Dental Examiners rules for documentation and records (TSBDE Rules 108.7 and 108.8); failure to meet these standards or provider qualifications may result in denial or sanctions.
- Follow TSBDE documentation and record maintenance standards (Rules 108.7 Minimum Standards of Care, General and 108.8 Records of Dentist).
- Maintain provider enrollment and qualifications required to provide each level of orthodontic service.
Do not authorize continuation of cases that began while Medicaid‑eligible; provide required evidence for privately‑started cases
Continuation requests for cases that began while the Member was Medicaid‑eligible will be denied; continuation of privately‑initiated cases may be considered only with required continuation documentation (Continuation of Care Form, prior approvals, payment history, study models, panorex, etc.).
- If case began while Medicaid eligible and was a private arrangement, continuation will be denied.
- To be considered, privately‑initiated cases require a completed Orthodontic Continuation of Care Form, ADA claim form listing services, a copy of prior approval and payment history, study models and panorex as applicable.
Unauthorized appliance removal may forfeit future orthodontic eligibility
If appliances are removed without authorization for reasons other than documented extenuating circumstances or a member request, the member may not be eligible for any additional Medicaid orthodontic services.
- Authorized removal for listed extenuating circumstances allows eligibility for re‑initiation if re‑started while Medicaid eligible.
- Removal for other reasons may render the member ineligible for further orthodontic benefits.
Definitions and Dentition Categories
Background and Scope
Severe handicapping malocclusion is an occlusion that is severely functionally compromised and is categorized by four Levels (I–IV) corresponding to escalating severity and treatment complexity. Level I addresses early mixed dentition problems and is expected to be completed within 12 months. Level II requires meeting four listed qualifying conditions (examples include full‑cusp Class II or III, overbite >5 mm, overjet >8 mm, anterior crowding >6 mm, generalized spacing >6 mm, and severely impacted maxillary canines with radiographic evidence) and is expected to be completed within 24 months. Level III applies to adolescent/adult dentition and also requires four qualifying conditions (examples include anterior impaction with radiographic evidence, anterior open bite >6 mm, posterior open bite >5 mm, or qualifying posterior crossbite patterns) with an expected completion within 36 months. Level IV is for adult dentition cases requiring orthognathic surgery with documentation from an oral surgeon; these surgical cases focus on functional correction (not esthetics) and are expected to be completed within 48 months. Documentation requirements for all levels include models, panorex, cephalogram, and clinical photographs as specified in prior authorization guidance.
Policy Revision History
Policy became effective for DentaQuest Dental Orthodontia Review.
Policy last reviewed and revised prior to the effective date.
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