Orthodontic Medical Necessity Criteria
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Defines medical necessity, documentation, provider eligibility, billing, and prior authorization requirements for orthodontic treatment for eligible New Mexico Medicaid members under age 21. Affects Turquoise Care MCOs and dental providers billing Medicaid.
Medical necessity criteria for handicapping malocclusions have been revised and take effect October 1, 2024.
Auto-qualifiers and a minimum HLD index score of 26 are specified as bases for medical necessity determination.
Prior authorization remains required for orthodontic services.
Orthodontic Medical Necessity Criteria
Medical necessity for orthodontic treatment
Covered when ANY of the auto-qualifier conditions are present, or when ALL of the HLD threshold criteria are met, or when qualifying medical or speech conditions documented as non-responsive to prior therapy exist.
Auto-qualifiers
- Cleft palate deformities and other significant craniofacial anomalies.
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- Deep impinging overbite when the lower incisors are touching the soft tissue (does not include occasional cheek biting).
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- Crossbite of individual anterior teeth in contact with soft tissue OR presence of more than two teeth in crossbite.
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- Impacted permanent cuspids and/or cases requiring surgical intervention (does not include ectopic eruption not requiring surgery).
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- Overjet in excess of 7 mm.> 7 mm
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Supported by chunk 1
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Anecdotal statements alone do not establish a handicapping malocclusion. Statements such as a patient “has difficulty eating, chewing, or speaking” must be supported by contemporaneous professional progress notes; unsupported or anecdotal information is considered insufficient documentation to meet medical necessity for orthodontic treatment.
Orthodontic treatment is not covered when the case does not meet any of the specified auto-qualifiers, does not have a Handicapping Labio-Lingual Deviation (HLD) score of ≥ 26, and lacks documentation showing a preexisting medical condition or speech pathology that was non-responsive to appropriate therapy without orthodontics. In such situations, coverage is not considered medically necessary.
Billing, Codes, and Thresholds
| ADA Dental Claim form | Dental providers will bill on an American Dental Association (ADA) Dental Claim form and follow eligibility requirements; reimbursed at no less than the dental fee schedule rate published at https://www.hsd.state.nm.us/providers/feeschedules/. |
| UB-04 | Federally Qualified Health Centers (FQHCs), non-hospital based Rural Health Clinics (RHCs), Indian Health Service (IHS) & eligible Tribal 638 may bill using the UB 04 institutional claim with the appropriate revenue code and appropriate dental procedure code as part of their visit/encounter; reimbursed according to their appropriate encounter/OMB rates. |
| Dental fee schedule | Reimbursement at no less than the dental fee schedule rate published at https://www.hsd.state.nm.us/providers/feeschedules/. |
| Effective October 1, 2024 | MCOs will allow and reimburse for orthodontic treatment when the medical necessity criteria and/or HLD are met, effective October 1, 2024. |
| 90-day implementation | MCOs are directed to implement changes, including system changes and provider contract negotiations, no later than 90 days from the date of issuance of this directive; LOD will sunset upon inclusion in NMAC 8.310.2.12.G. |
Prior Authorization and Documentation Requirements
Prior authorization required
Prior authorization is required for orthodontic services; providers must submit the required orthodontic records and a treatment plan to obtain authorization.
Conservative treatment / non‑response documentation
When no auto-qualifier is present and HLD < 26, document that the medical condition or speech pathology predated the orthodontic request and was non-responsive to appropriate medical or speech therapy without orthodontic treatment.
- Medical condition/nutritional deficiency must be documented in physician progress notes predating the diagnosis/request and shown non-responsive to medical treatment without orthodontics.
- Speech pathology must be documented in speech therapy progress notes predating the diagnosis/request and shown non-responsive to speech therapy without orthodontics.
Required documentation for prior authorization
Submit completed orthodontic records and a treatment plan that include diagnosis, length and type of treatment, prognosis, probability of compliance, and whether orthognathic surgery is planned; required records are listed below.
- Diagnostic casts or digital study models
- Full mouth or panoramic x-ray
- Cephalometric film
- Diagnostic photographs
- Completed orthodontic screening form stating the HLD score and indicating the handicapping malocclusion
Denial risk if not authorized
Absence of prior authorization for orthodontic services may result in denial of coverage; obtain authorization before providing services.
Insufficient documentation risk
Anecdotal statements (for example, claims of difficulty eating, chewing, or speaking) that are not supported by professional progress notes are insufficient documentation and may lead to denial.
- Progress notes from physicians or speech therapists must document the condition and predate the orthodontic request where applicable.
- Do not rely on unsupported patient/guardian statements; include objective clinical records listed in required documentation.
Clinical Background
Orthodontic treatments address malocclusions—misalignment of the teeth and/or jaws—that interfere with normal oral function. The policy uses the Handicapping Labio-Lingual Deviation (HLD) index to quantify severity; when no auto-qualifying condition is present, a minimum HLD score of 26 is required to meet medical necessity. Specific auto-qualifiers that automatically meet medical necessity include cleft palate and other significant craniofacial anomalies, deep impinging overbite when lower incisors contact soft tissue, certain crossbites (anterior teeth contacting soft tissue or more than two teeth in crossbite), impacted permanent cuspids or cases requiring surgical intervention, and an overjet greater than 7 mm.
Key Definitions
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