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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4. Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.24 Orthodontic Services (THSteps) : 4.2.24.1 Benefits and Limitations

4.2.24.1
Orthodontic services include the following:
Correction of severe handicapping malocclusion as measured on the Handicapping Labiolingual Deviation (HLD) Index. A minimum score of 26 points is required for full banding approval (only permanent dentition cases are considered).
Refer to:
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 or outline of the proposed treatment plan when requesting authorization for orthodontic services on cleft palate cases.
The following limitations apply for orthodontic services:
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.
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 ceases to be a Medicaid provider for any reason, a new prior authorization must be requested by the new provider.
Refer to:
The following procedure codes, policies, and limitations are applied to the processing and payment of orthodontic services under THSteps dental services:
The client is referred to a dental provider to determine whether orthodontic services are indicated and to determine the appropriate time to initiate such services.
If procedure code D8660 is submitted within six months of procedure code D8080, procedure code D8080 will be reduced by the amount that was paid for procedure code D8660.
Procedure code D8680 is payable for one retainer per arch, per lifetime, and each retainer may be replaced once because of loss or breakage (prior authorization is required).
Procedure code D8670 must be submitted only when an adjustment to the appliances is provided and may not be submitted before the date on which 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.
Special orthodontic appliances may also be used with full banding and crossbite therapy with approval by the TMHP Dental Director.
Exception:
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 workup for procedure codes used that were necessary to request the prior authorization (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 workup.
Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are 12 years of age and older or clients who have exfoliated all primary dentition. Crossbite therapy includes diagnostic cast services.

Texas Medicaid & Healthcare Partnership
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