CurrentNew Mexico Health Care AuthorityPolicy N/A

Dental services — Orthodontics and Silver Diamine Fluoride (SDF) coverage criteria

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Governs Medicaid coverage, provider requirements, and medical necessity criteria for dental services (including orthodontics and silver diamine fluoride) for New Mexico Medicaid members, including EPSDT-eligible recipients and providers enrolled with New Mexico Medicaid.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyDental services — Orthodontics and Silver Diamine Fluoride (SDF) coverage criteria

Policy CodePolicy N/A

Change TypeMinor/technical (no material clinical or coverage changes)

Effective DateJul 1, 2024

Last ReviewJan 31, 2025

Next Review DateJan 31, 2025

Key ActionSubmit completed orthodontic records and a treatment plan including diagnosis, HLD score, diagnostic images, and required documentation when requesting orthodontic coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Orthodontic eligible recipient age limit

HLD ≥ 26HLD threshold (no auto-qualifier)

Max 2/12moSDF per-tooth per 12 mo

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CurrentNew Mexico Health Care AuthorityPolicy N/A

Dental services — Orthodontics and Silver Diamine Fluoride (SDF) coverage criteria

Customize your policy alerts

Sign up for all New Mexico Health Care Authority policy alerts

Know when New Mexico Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyDental services — Orthodontics and Silver Diamine Fluoride (SDF) coverage criteria

Policy CodePolicy N/A

Change TypeMinor/technical (no material clinical or coverage changes)

Effective DateJul 1, 2024

Last ReviewJan 31, 2025

Next Review DateJan 31, 2025

Key ActionSubmit completed orthodontic records and a treatment plan including diagnosis, HLD score, diagnostic images, and required documentation when requesting orthodontic coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Orthodontic eligible recipient age limit

HLD ≥ 26HLD threshold (no auto-qualifier)

Max 2/12moSDF per-tooth per 12 mo

SDF per-tooth lifetime

Up to 5Teeth per SDF session

Coverage and Medical Necessity Criteria

Orthodontic medical necessity

Covered when medical necessity for a handicapping malocclusion is demonstrated by either an auto-qualifier OR the HLD-based pathway; additional indicators may be considered if neither threshold is met.

Medical necessity for orthodontics: Covered when ANY of the following are met:

Auto qualifiers: Any one of the following auto-qualifier conditions qualifies: cleft palate deformities and other significant craniofacial anomalies; deep impinging overbite when the lower incisors are touching the soft tissue (does not include occasional biting of the cheek); anterior tooth crossbite contacting soft tissue or the presence of more than two teeth in crossbite; impacted permanent cuspids requiring surgical intervention (does not include ectopic eruption cases); overjet in excess of 7 mm.

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HLD index: If no auto-qualifier is present, a minimum Handicapping Labio-Lingual Deviation (HLD) score of 26 or greater meets medical necessity.HLD >= 26

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Additional indicators considered: If neither an auto-qualifier nor HLD >= 26 are met, consider documented medical conditions or nutritional deficiencies with physiologic impact (documented in physician progress notes predating the orthodontic diagnosis/request and non-responsive to medical treatment) OR documented speech pathology (documented in speech therapy progress notes predating the orthodontic diagnosis/request and non-responsive to speech therapy) as indicators supporting medical necessity.

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Silver diamine fluoride coverage

SDF is covered when applied according to the eligibility, provider, and application limits below and when documented in the member's medical or dental record.

SDF recipient indications: Covered for: children too young for conventional restorative treatment in a dental chair; members unable to undergo conventional dental treatment; older adults with limited access to dental facilities; people with special needs who are unable to cooperate with dental treatment.

chunks 6 and 9

SDF provider eligibility: Covered when furnished by enrolled New Mexico Medicaid providers: dental providers (dentist, dental clinic/RHC, dental hygienist, FQHC) for dental service pathway, or medical providers (physician, certified nurse practitioner, certified nurse specialist, physician assistant) when provided under the medical provider pathway per MAD rules.

chunks 6 and 6

SDF application limits: Apply a maximum of 2 treatments per tooth per 12-month period; up to 5 teeth may be treated per session on one claim; maximum of 4 treatments per tooth in a lifetime.2 per tooth/12 months; up to 5 teeth/session; 4 per tooth lifetime

Anecdotal statements that are not supported by professional progress notes do not meet the standard for medical necessity when documenting a handicapping malocclusion. Examples include unsupported claims that a member has difficulty with eating, chewing, or speaking if those claims are not corroborated by clinical findings or progress notes. Such statements may reflect other medical conditions rather than a malocclusion and therefore are insufficient evidence to establish coverage for orthodontic services.

For orthodontic coverage, cases documented solely with anecdotal information do not meet medical necessity. The record must include professional documentation (for example, progress notes and a completed orthodontic screening form with an HLD score) rather than only patient- or caregiver-reported complaints in order to support treatment authorization.

Billing and Codes

SDF codesCPTCovered

D1354	Topical application of a caries arresting medicament; dental provider
0792T	Topical application of a caries arresting medicament; medical provider

Orthodontics provider codesmixed

Provider type 421	Dentist (eligible provider for orthodontics)
Taxonomy 122300000X	Dentist taxonomy

inv-07: HLD threshold — numeric threshold for HLD index (>= 26)

HLD index thresholdMinimum score of 26 points (HLD ≥ 26) required when no auto-qualifier is present

PurposeHLD measures the severity of a handicapping malocclusion

ApplicationUsed to determine medical necessity for orthodontic treatment if no auto-qualifier applies

Provider Requirements and Billing Actions

Prior Authorization

SDF prior authorization — not required for D1354 or 0792T

Prior authorization is not required for silver diamine fluoride (SDF) when billed with D1354 (dental providers) or 0792T (medical providers). When billing, use D1354 for dental providers and 0792T for medical providers as described in the SDF sections; no separate prior authorization submission is necessary for these codes.

D1354: topical application of a caries-arresting medicament (dental providers).
0792T: topical application of a caries-arresting medicament (medical providers).

Step Therapy

Documentation and step therapy — none specified; exam and indication required

No step therapy is specified for SDF; however, providers must document the clinical indication and perform a comprehensive examination with findings recorded in the member's record prior to SDF application.

Document indication for SDF application in the member's record.

Background and Purpose

Orthodontic treatment is intended to correct malocclusions—misalignments of the teeth and/or jaws—that cause a disability in normal oral function. The HCA defines medical necessity for orthodontics by requiring objective documentation of a handicapping malocclusion; anecdotal statements alone are insufficient. Providers must document clinical findings (including a completed orthodontic screening form with the Handicapping Labio-Lingual Deviation HLD score) and supporting progress notes to establish eligibility for orthodontic services.

Key Definitions

inv-14: Auto qualifier (orthodontics) — list of specific conditions that automatically meet medical necessity

Cleft palate / craniofacial anomaliesAutomatic qualifier for medical necessity

Deep impinging overbiteLower incisors touching soft tissue (excludes occasional cheek biting) — auto qualifier

Anterior crossbite contacting soft tissue or >2 teeth in crossbiteAuto qualifier

Impacted permanent cuspids requiring surgical interventionAuto qualifier (does not include ectopic eruption cases)

Overjet > 7 mmOverjet in excess of 7 mm is an auto qualifier

inv-15: Handicapping Labio-Lingual Deviation (HLD) index — definition and threshold for medical necessity

Policy Summary

PayerNew Mexico Health Care Authority

PolicyDental services — Orthodontics and Silver Diamine Fluoride (SDF) coverage criteria

Policy CodePolicy N/A

Change TypeMinor/technical (no material clinical or coverage changes)

Effective DateJul 1, 2024

Last ReviewJan 31, 2025

Next Review DateJan 31, 2025

Key ActionSubmit completed orthodontic records and a treatment plan including diagnosis, HLD score, diagnostic images, and required documentation when requesting orthodontic coverage.

SourceLink

On This Page

Prior authorization and documentation: Prior authorization is not required for SDF (e.g., when billed with D1354 for dental providers); however requirements and indications must be documented in the member's record, including evidence of a comprehensive dental examination by a licensed dental practitioner (for dental pathway) or clinical evidence of caries assessed by an eligible medical provider (for medical pathway). Providers must document the tooth number(s) and indication prior to application.

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Record results of the comprehensive examination performed prior to treatment.

Documentation Required

Orthodontic record submission — completed records and full treatment plan required

Submit completed orthodontic records and a treatment plan that include required diagnostic materials and plan details; the treatment plan must state diagnosis, length and type of treatment, prognosis, and probability of compliance.

Diagnostic casts or digital study models.
Full mouth or panoramic x-ray and cephalometric film.
Diagnostic photographs.
A completed orthodontic screening form with the HLD score and indication of the handicapping malocclusion.
Treatment plan documenting diagnosis, length and type of treatment, favorable prognosis, probability of compliance, and whether orthognathic surgery is planned.

Documentation Required

SDF by dental providers — exam, consent, and tooth identification required

For SDF furnished by dental providers, ensure a comprehensive dental examination by a licensed dental practitioner with documented consent to treat and identification of the tooth number(s) to be treated before applying the medicament.

Comprehensive dental examination by a licensed dental practitioner prior to application.
Documented consent to treat in the record.
Indication of tooth number(s) to be treated documented before SDF application.

Denial Risk

Denial risk — anecdotal information alone is insufficient

Anecdotal statements alone are insufficient to establish a handicapping malocclusion and may lead to denial; providers must support claims (e.g., difficulty eating, chewing, or speaking) with professional progress notes and objective documentation.

Do not rely on unsupported patient or caregiver statements as documentation of functional impairment.
Include professional progress notes and objective findings to substantiate handicapping malocclusion.

DefinitionHandicapping Labio-Lingual Deviation (HLD) measures the severity of a handicapping malocclusion

Threshold for medical necessityMinimum HLD score of 26 points (HLD ≥ 26) when no auto-qualifier is present

Use caseApply HLD scoring to determine orthodontic coverage eligibility if none of the auto-qualifier conditions are met