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19.18.1 Benefits and Limitations
Orthodontic services include the following:
• Correction of severe handicapping malocclusion as measured on the Handicapping Labiolingual Deviation (HLD) Index. Refer to page 19-42 for information on how to score the HLD. A minimum score of 26 points is required for full banding approval (only permanent dentition cases are considered).
Exception: Retained deciduous teeth and cleft palates with gross malocclusion that will benefit from early treatment. Cleft palate cases do not have to meet the HLD 26-point scoring requirement. However, it is necessary to submit a sufficient narrative and/or outline of the proposed treatment plan when requesting authorization for orthodontic services on cleft palate cases.
•Crossbite therapy.
•Head injury involving severe traumatic deviation.
The following limitations apply for orthodontic services:
•Orthodontic services for cosmetic purposes only are not a benefit of the Texas Medicaid Program or THSteps.
•Orthognathic surgery, to include extractions, required or provided in conjunction with the application of braces must be completed while the client is Medicaid-eligible in order for reimbursement to be considered.
•Except for D8660, all orthodontic procedures require prior authorization for consideration of reimbursement.
•The THSteps client must be Medicaid/THSteps-eligible when authorization is requested and the orthodontic treatment plan is initiated. It is the provider's responsibility to see that the client has a current Medicaid Identification Form (Form H3087) or Medicaid Eligibility Verification Form (Forms H1027 and H1027-A-C) and that the date of birth on the form indicates the client is younger than 21 years of age and no limitations are indicated.
•Prior authorization is issued to the requesting provider only and is not transferable to another provider. If the client changes providers or if the provider stops practicing dentistry in the Texas Medicaid Program for whatever reason, a new prior authorization must be requested (see "Transfer of Orthodontic Services" ).
The following procedure codes, policies, and limitations are applied to the processing and payment of orthodontic services under THSteps dental services:
•Procedure code D8660 is allowed when:
•The client is referred to an orthodontist for a determination of whether orthodontic services are indicated and to determine the appropriate time to initiate such services.
•The client is referred to an orthodontist and elects to receive services from another orthodontic provider because of justifiable reasons.
•Repeat visits at different age levels are required to determine the appropriate time to initiate orthodontic treatment.
•Procedure code D8680 is payable for one retainer per arch, per lifetime, and may be replaced once because of loss or breakage (prior authorization is required).
•Procedure code D8670 should be billed only when an adjustment to the appliances is provided and may not be billed before the date the orthodontic adjustment was performed. The number of visits for monthly adjustments to the appliances is restricted to the number that was authorized in the treatment plan. However, the number of monthly visits may be amended with appropriate documentation of medical necessity while the client is Medicaid eligible.
•Procedure code D8670 is paid only in conjunction with a history of braces (code D8080), unless special circumstances exist.
•All orthodontic codes and appliances are global fees.
•Separate fees for adjustments to retainers are not payable.
•The appropriate code should be billed for those appli- ances required as part of the treatment of cleft palate cases.
Special orthodontic appliances may also be used with full banding and crossbite therapy with approval by the TMHP Dental Director.
•Procedure codes D5951, D5952, D5953, D5954, D5955, D5958, D5959, and D5960 are to be used as applicable with documentation of medical necessity. Otherwise, use the appropriate special orthodontic appliance code.
•Full banding is allowed on permanent dentition only, and treatment should be accomplished in one stage and is allowed once per lifetime.
Exception: Cases of mixed dentition when the treatment plan includes extractions of remaining primary teeth or cleft palate.
•Crossbite therapy is allowed for primary, mixed, or permanent dentition.
•Providers must not request crossbite correction (limited orthodontics) for a mixed dentition client when there is a need for full banding in the adult teeth. Crossbite therapy is an inclusive charge for treating the crossbite to completion, and additional reimbursement is not provided for adjustments or maintenance.
•If a case is not approved, the dentist may file a claim for payment of the diagnostic work-up necessary to obtain the authorization using procedure codes D0330, D0340, D0350, and D0470. The dentist may receive payment under these procedure codes for no more than two cases out of every ten cases denied. The dentist should determine if the client's condition meets orthodontic benefit criteria before performing a diagnostic work-up.
•Procedure codes D8080, D8050, and D8060, are limited to one per lifetime.
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