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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4 Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.27 Orthodontic Services (THSteps) : Other Orthodontic Services
Replacement brackets (procedure code D8690) are a benefit when the client transfers from one provider to another or when trauma is involved.
Providers are responsible for any replacement brackets that are required as part of the comprehensive orthodontic treatment. Additional reimbursement for replacement brackets (procedure code D8690) is limited to a combined total amount of $100.00, same provider.
Rebonding or recementing of fixed orthodontic appliances (procedure code D8693) may be reimbursed once per lifetime per orthodontic appliance.
Only one retainer per arch per lifetime (procedure code D8680) is allowed; however, each retainer may be replaced with prior authorization once per lifetime due to loss or breakage. Retainer adjustments are not reimbursed separately.
Appliances required as part of the cleft palate treatment plan may be reimbursed separately.
Special orthodontic appliances may be used with full banding and crossbite therapy when approved by the TMHP Dental Director or Associate Dental Director.

Texas Medicaid & Healthcare Partnership
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