CurrentNew Mexico Health Care AuthorityPolicy N/A

Dental services — orthodontics and silver diamine fluoride (SDF) coverage criteria

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Governs coverage, provider eligibility, documentation, and medical necessity criteria for dental services in New Mexico Medicaid, including orthodontics for recipients under age 21 and use of silver diamine fluoride by dental and medical providers.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyDental services — orthodontics and silver diamine fluoride (SDF) coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2024

Last ReviewJan 31, 2025

Next Review DateJan 31, 2025

Key ActionSubmit completed orthodontic records and treatment plan including diagnostic casts or digital models, radiographs, photos, prognosis and HLD score when requesting orthodontic coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Orthodontics eligible recipient age limit

HLD ≥ 26Orthodontic medical necessity threshold

D1354 / 0792TSDF billing codes

Max 2/12mo

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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 TypeNo material change

Effective DateJul 1, 2024

Last ReviewJan 31, 2025

Next Review DateJan 31, 2025

Key ActionSubmit completed orthodontic records and treatment plan including diagnostic casts or digital models, radiographs, photos, prognosis and HLD score when requesting orthodontic coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Orthodontics eligible recipient age limit

HLD ≥ 26Orthodontic medical necessity threshold

D1354 / 0792TSDF billing codes

Max 2/12mo

SDF frequency limits (per tooth)

Coverage and Medical Necessity Criteria

Orthodontics — Medical Necessity Criteria

Orthodontic treatment is covered when medical necessity is demonstrated for handicapping malocclusions as follows:

Auto qualifiers

Auto qualifier list: 1) Cleft palate deformities and other significant craniofacial anomalies; 2) Deep impinging overbite when the lower incisors are touching the soft tissue (does not include occasional biting of the cheek); 3) Crossbite of individual anterior teeth in contact with soft tissue or presence of more than two teeth in crossbite; 4) Impacted permanent cuspids and/or need for surgical intervention (does not include cases where cuspids or incisors will erupt ectopically); 5) Overjet in excess of 7 mm.

HLD threshold: If no auto qualifier is present, Handicapping Labio‑Lingual Deviation (HLD) index score must be >= 26 to meet medical necessityHLD >= 26

HLD measures the severity of a handicapping malocclusion.

Additional indicators: If neither auto qualifiers nor HLD >= 26 are met, the following may be considered: 1) A documented medical condition and/or nutritional deficiency with physiological impact, recorded in physician progress notes predating the orthodontic diagnosis and request, that is non‑responsive to medical treatment without orthodontic treatment; 2) Presence of a speech pathology documented in speech therapy progress notes predating the orthodontic diagnosis and request that is non‑responsive to speech therapy without orthodontic treatment.

These indicators require documentation in progress notes that predate the orthodontic request.

Silver Diamine Fluoride (SDF) — Coverage Criteria

SDF application is covered when documentation and indications are met:

Eligible recipients and indications: SDF is covered for members when documented indications exist: 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; and people with special needs who cannot cooperate with dental treatment.

Applies to both dental and qualified medical providers when documentation is present in the member's record.

Documentation and provider eligibility: For dental providers: evidence of a comprehensive dental examination by a licensed dental practitioner and consent to treat with tooth number(s) documented. Dental providers must be enrolled New Mexico Medicaid providers with the required provider type/specialty codes. For medical providers (physician, CNP, CNS, PA): clinical evidence of caries assessed by the provider and documented in the medical record; medical providers must be New Mexico Medicaid enrolled eligible practitioners.

Prior authorization is not required for SDF services.

Service limits: Maximum 2 treatments per tooth per 12‑month period; may be used on up to 5 teeth per session on a single claim; maximum of 4 treatments per tooth in a lifetime.

Anecdotal statements alone do not meet documentation requirements for orthodontic medical necessity. The policy specifies that statements not supported by professional progress notes—such as reports that a patient “has difficulty with eating, chewing, or speaking”—are considered anecdotal information and are insufficient to establish a handicapping malocclusion. Such claims may be caused by other medical conditions and therefore require corroborating progress notes from treating professionals.

Requests for orthodontic services based solely on anecdotal information will be denied as not medically necessary. Providers must include supporting professional progress notes and objective documentation (for example, a completed orthodontic screening form and diagnostic records) rather than unverified patient or caregiver statements.

Procedure Codes and Frequency Limits

SDF — Dental provider procedure codesCPT | HCPCSCovered

D1354

Application of topical fluoride — caries arresting medicament (dental provider)

SDF — Medical provider procedure codesCPT | HCPCSCovered

0792T

Topical application of caries arresting medicament (medical provider)

SDF treatment frequency limits

Maximum treatments per toothMaximum 2 treatments per tooth per 12-month period.

Teeth per session limitMay be used on up to 5 teeth per session on one claim.

Lifetime limit per toothMaximum of 4 treatments per tooth in a lifetime.

Provider Requirements, Documentation, and Billing Notes

Prior Authorization

No prior authorization required for SDF

Prior authorization is not required for silver diamine fluoride (SDF) services (codes D1354 for dental providers and 0792T for medical providers).

Step Therapy

Include prior non‑responsive medical or speech therapy as supporting evidence

When considering orthodontic requests, include documentation of prior non‑responsive medical treatment or speech therapy in professional progress notes that predate the orthodontic diagnosis/request to support medical necessity.

Progress notes must predate the orthodontic diagnosis and request.
Documentation must show the condition was non‑responsive to the prior therapy.

Key Definitions and Indices

Handicapping Labio‑Lingual Deviation (HLD) index

DefinitionHandicapping Labio‑Lingual Deviation (HLD) is a measured index of severity of a handicapping malocclusion used to determine orthodontic medical necessity.

Threshold for medical necessityIf no auto qualifier is present, a minimum HLD score of 26 points or greater is required to meet orthodontic medical necessity (HLD ≥ 26).

UseHLD is used when auto‑qualifying conditions are not present to assess severity of malocclusion for coverage decisions.

Auto qualifiers (orthodontics)

Cleft palate and craniofacial anomaliesCleft palate deformities and other significant craniofacial anomalies.

Deep impinging overbiteDeep impinging overbite when the lower incisors are touching the soft tissue (does not include occasional cheek biting).

Background and Clinical Rationale

Orthodontic treatment is intended to correct malocclusions—misalignment of the teeth and/or jaws—that cause a disability in normal oral function. Medical necessity for orthodontics is determined by either an auto‑qualifying condition (such as cleft palate/craniofacial anomalies, deep impinging overbite with soft tissue contact, certain anterior crossbites, impacted permanent cuspids requiring surgical intervention, or excessive overjet) or by the Handicapping Labio‑Lingual Deviation (HLD) index. When no auto‑qualifier is present, the HLD score is used to assess severity and eligibility for coverage. Providers must document the condition with appropriate diagnostic records and the completed orthodontic screening form stating the HLD score to support the clinical rationale for treatment.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyDental services — orthodontics and silver diamine fluoride (SDF) coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2024

Last ReviewJan 31, 2025

Next Review DateJan 31, 2025

Key ActionSubmit completed orthodontic records and treatment plan including diagnostic casts or digital models, radiographs, photos, prognosis and HLD score when requesting orthodontic coverage.

SourceLink

On This Page

Maximum 2 treatments per tooth per 12 months; maximum 4 treatments per tooth lifetime

Code D1354 (dental providers) and 0792T (medical providers) describe topical application of a caries‑arresting medicament; prior authorization is not required.

Documentation Required

Submit full orthodontic records and treatment plan

Submit completed orthodontic records and a treatment plan that include diagnosis, length and type of treatment, documentation of a favorable prognosis, probability of compliance, and whether orthognathic surgery is planned. Records must include diagnostic casts or digital study models, full mouth or panoramic x‑ray, cephalometric film, and diagnostic photographs.

Documentation Required

Provide completed orthodontic screening form with HLD score

Include a completed orthodontic screening form that states the Handicapping Labio‑Lingual Deviation (HLD) score and indicates the handicapping malocclusion; the provider may submit the original or a copy.

Documentation Required

Document exam, consent, and tooth numbers for dental SDF

For SDF provided by dental providers, document a comprehensive dental examination by a licensed dental practitioner with consent to treat and indicate the tooth number(s) prior to application of the medicament.

Comprehensive dental exam by a licensed dental practitioner is required prior to application.
Obtain and document consent to treat.
Record tooth number(s) treated.

Documentation Required

Document clinical evidence of caries for medical-provider SDF

For SDF provided by physicians or other qualified medical professionals (physician, CNP, CNS, PA), document clinical evidence of caries assessed by the treating provider in the member's medical record to meet eligibility and reimbursement requirements.

Clinical evidence of caries must be documented in the medical record by the assessing medical provider.
Eligible medical providers include physicians, CNPs, CNSs, and PAs who are enrolled Medicaid providers.

Denial Risk

Progress notes required—anecdotal information insufficient

Anecdotal statements alone are insufficient to document a handicapping malocclusion; include professional progress notes (not anecdotal reports) to substantiate claims such as difficulty eating, chewing, or speaking.

Statements about functional difficulty must be supported by professional progress notes.
Anecdotal reports without documentation may lead to denial as not medically necessary.

Anterior crossbiteCrossbite of individual anterior teeth in contact with soft tissue or presence of more than two teeth in crossbite.

Impacted permanent cuspids or surgical interventionImpacted permanent cuspids and/or cases requiring surgical intervention (excludes ectopic eruption cases).

Excessive overjetOverjet in excess of 7 mm.