Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.
Effective for dates of service on or after October 1, 2024, orthodontic dental benefit criteria will change for Texas Health Steps.
The changes to orthodontic services benefit criteria are summarized as follows:
- Procedure code D8070 will become a benefit of Texas Medicaid.
- Level I, II, and III orthodontic services will be defined.
New Orthodontic Benefit
Procedure code D8070 will become a benefit of Texas Medicaid with prior authorization for clients who are birth through 20 years of age and will be limited to once per lifetime, by any provider.
Procedure code D8070 may be reimbursed to federally qualified health center (FQHC), Texas Health Steps dental and dental group, orthodontist, and local health department providers for services rendered in the office setting.
Level I, II, and III Orthodontic Services
Texas Medicaid recognizes three orthodontic service levels for severe handicapping malocclusion. Each service level requires a different amount of time for treatment.
Prior authorization is required for all levels of orthodontic services. Prior authorization requests must include the number of monthly visits and the expected completion time according to the corresponding treatment level.
Level I Orthodontic Services
Level I orthodontic services are dedicated to the resolution of early signs of handicapping malocclusion in early mixed dentition that may significantly impact the health of the developing dentition, alveolar bone, and symmetrical growth of the skeletal framework.
Exceptions for cases of mixed dentition may be considered when the treatment plan includes extractions of the remaining primary teeth or in the case of a cleft palate.
Evidence of one of the following conditions should be clearly visible and submitted in the supporting documentation:
- An anterior crossbite that is associated with clinically apparent severe gingival inflammation or recession or severe enamel wear
- A posterior crossbite with an associated midline deviation and asymmetric closure pattern
- Dental crossbites other than those described above will not be eligible for treatment in level I. However, special orthodontic appliances are a benefit for minor treatment to control harmful habits.
The following procedure codes may be reimbursed for level I orthodontic services:
| Level I Orthodontic Services Procedure Codes | |
|---|---|
| D8210 | D8220 |
Level II Orthodontic Services
Level II orthodontic services are dedicated to the resolution of handicapping malocclusion in the transitional dentition, which is the final phase of the transition from primary to adolescent dentition during which the succedaneous permanent teeth are emerging or about to emerge.
The following procedure codes may be reimbursed for level II orthodontic services:
| Level II Orthodontic Services Procedure Codes | ||||||
|---|---|---|---|---|---|---|
| D8010 | D8020 | D8070 | ||||
Providers must use the appropriate procedure code for banding.
Level III Orthodontic Services
Level III orthodontic services are dedicated to the resolution of handicapping malocclusion in the adolescent dentition, which is indicated by the complete eruption of the permanent dentition, with the possible exception of the full eruption of the second molars.
The following procedure code may be reimbursed for level III orthodontic services:
| Level III Orthodontic Services Procedure Codes | ||||||
|---|---|---|---|---|---|---|
| D8080 | ||||||
Completion or Premature Termination of Orthodontic Services
The completion of orthodontic services includes the construction of both maxillary and mandibular retainers in addition to the removal of all bands, brackets, and appliances.
Premature termination of orthodontic services includes all of the following:
- The removal of brackets and arch wires
- Ending the use of other special orthodontic appliances
- Ending the fabrication of special orthodontic appliances
- Ending the delivery of orthodontic retainers
The following procedure code may be reimbursed for the completion or premature termination of orthodontic services:
| Completion of Orthodontic Services Procedure Code | ||||||
|---|---|---|---|---|---|---|
| D8680 | ||||||
Noncovered Services
An initial orthodontic or preorthodontic treatment visit (procedure code D8660) is considered part of the exam in an oral evaluation (procedure code D0120, D0150, or D0160).
Prior Authorization for Level I Orthodontic Services
The following documentation must be submitted with a prior authorization request for level I orthodontic services (procedure code D8210 or D8220):
- Radiographs (x-rays)
- Photographs
- Treatment plan
- Narrative of medical necessity
The completion of level I orthodontic services does not disqualify future level II or level III orthodontic services.
Prior authorization will not be granted for level I orthodontic services if there is an indication that the client will qualify for level II or level III orthodontic services in the future.
Prior Authorization for Level II Orthodontic Services
The following documentation must be submitted with a prior authorization request for level II orthodontic services (procedure code D8070):
- Digital diagnostic models or other type of 3D diagnostic images
- Radiographs (x-rays)
- Cephalometric radiographic image with tracings
- Photographs
- Treatment plan
- Narrative of medical necessity
Evidence of four of the following conditions must be submitted in the supporting documentation:
- Full cusp class II malocclusion with the distal buccal cusp of the maxillary first molar occluding in the mesial buccal groove of the mandibular first molar
- Full cusp class III malocclusion with the maxillary first molar occluding in the embrasure distal to the mandibular first molar or on the distal incline of the mandibular molar distal buccal cusp
- Overbite measurement of more than 5 mm
- Overjet measurement of more than 8 mm
- More than four congenitally absent teeth, including at least one anterior tooth
- Anterior crowding of more than 6 mm in the mandibular arch
- Anterior crossbite of at least two of the four maxillary incisors
- Generalized spacing in both arches of more than 6 mm in each arch
- Early impacted maxillary canine or mandibular canines, supported by radiographs indicating a severe mesial angulation of the erupting canine and the crown of the canine superimposed on and crossing the image of the maxillary lateral incisor
Prior Authorization for Level III Orthodontic Services
The following documentation must be submitted with a prior authorization request for level III orthodontic services (procedure code D8080):
- Digital diagnostic models or other type of 3D diagnostic images
- Radiographs (x-rays)
- Cephalometric radiographic image with tracings
- Photographs
- Treatment plan
- Narrative of medical necessity
Evidence of four of the following conditions must be submitted in the supporting documentation:
- Full cusp class II malocclusion with the distal buccal cusp of the maxillary first molar occluding in the mesial buccal groove of the mandibular first molar
- Full cusp class III malocclusion with the maxillary first molar occluding in the embrasure distal to the mandibular first molar or on the distal incline of the mandibular molar distal buccal cusp
- Anterior tooth impaction: unerupted with radiographic evidence to support a diagnosis of impaction (lack of eruptive space, angularly malposed, and totally imbedded in the bone) as compared to ectopically erupted anterior teeth that may be malposed but have erupted into the oral cavity and are not a qualifying element
- Anterior crowding of more than 6 mm in the mandibular arch
- Anterior open bite demonstrating that all maxillary and mandibular incisors have no occlusal contact and are separated by more than 6 mm
- Posterior open bite should demonstrate a vertical separation by more than 5 mm for several posterior teeth, not to be confused with the delayed natural eruption of a few teeth
- Posterior crossbite with an associated midline deviation and mandibular shift, a Brodie bite with a mandibular arch totally encumbered by an overlapping buccally occluding maxillary arch, or a posterior maxillary arch totally lingually malpositioned to the mandibular arch
- Anterior crossbite should include more than two incisors in crossbite and demonstrate gingival inflammation, gingival recession, or severe enamel wear
- Overbite of more than 5 mm
- Overjet of more than 8 mm
Additional Services
There may be exceptional circumstances that require additional treatment time, including but not limited to cases of craniofacial anomalies and cleft palate. Prior authorization for additional services will be reviewed and evaluated on an individual basis for medical necessity.
Prior authorization requests for additional services (procedure code D8670) must include the following:
- The reason for the additional monthly visits and the number of visits requested
- The name of the additional appliance in the case of a cleft palate treatment plan, if needed
- Recent radiographs (x-rays) showing the progress made to date
- Current photographs
- Current treatment plan
Additional treatment months may be considered for one of the following circumstances:
- The client is a child of a migrant farm worker.
- The client’s orthodontic services were delayed because the client was temporarily in state custodial care (foster care).
Completion of All Levels of Orthodontic Services
Prior authorization is required for the completion of treatment (last payment) and must be reviewed for proof of the completion of the case.
A prior authorization request for the completion of level II or level III (procedure code D8680) services must include the following:
- A post-treatment panoramic radiographic image
- Photographs
- A signed statement from the treating provider that the treatment is complete
Premature Termination of Orthodontic Services
Prior authorization is required for the premature termination of appliances (procedure code D8680).
The prior authorization request must include the following:
- A release form (or a copy) that must be signed by the parent or legal guardian or by the client if they are 18 years of age or older or an emancipated minor
- Documentation of one of the following:
- The client is uncooperative or noncompliant.
- The client requested the removal of orthodontic appliances.
- The client requested the removal of appliances due to exceptional circumstances, such as incarceration.
- The client has mental health complications with a recommendation from the treating physician.
- The client is in a foster care placement.
- The client is a child of a migrant farm worker and intends to complete treatment later if Medicaid eligibility for orthodontic services continues.
Reimbursement
The diagnostic workup is considered part of the preorthodontic visit (procedure code D8660). Reimbursement for the preorthodontic visit (procedure code D8660) may be considered when all bands, brackets, and appliances have been placed and active treatment has been initiated.
Procedure codes D0330, D0340, D0350, D0470, and D8660 will be denied when submitted with procedure codes D8070 and D8080.
Level I orthodontic services (procedure codes D8210 and D8220) are limited to once per arch, per lifetime, by any provider.
The orthodontic diagnostic workup procedures are considered part of the services provided under procedure codes D8210 and D8220 and are not reimbursed separately.
Panoramic radiographic images (procedure code D0330), cephalometric radiographic images (procedure code D0340), oral or facial photographic images obtained intraorally or extraorally (procedure code D0350), and diagnostic models (procedure code D0470) will be denied when billed with procedure code D8210 or D8220.
The orthodontic diagnostic workup procedures are considered part of the services provided under procedure codes D8010 or D8020 and are not reimbursed separately. Panoramic radiographic images (procedure code D0330), cephalometric radiographic images (procedure code D0340), oral or facial photographic images obtained intraorally or extraorally (procedure code D0350), and diagnostic models (procedure code D0470) will be denied when billed with procedure code D8010 or D8020.
Level I, II, and III orthodontic services (procedure codes D8010, D8020, D8070, D8080, and D8680) are limited to once per lifetime, by any provider.
Procedure code D0160 will be denied when submitted on the same date of service as procedure code D8080.
Cleft or craniofacial cases are eligible for more than one level of orthodontic services (level II and level III) per lifetime.
The following procedure codes may be reimbursed for additional comprehensive orthodontic services:
| Procedure Codes | ||||||
|---|---|---|---|---|---|---|
| D8660 | D8670 | |||||
Procedure codes D8080, D8210, D8220, D8660, and D8680 will no longer be reimbursed to oral maxillofacial surgeon providers.
The length of treatment depends on the level of orthodontic services that the client receives as indicated below:
- Level I allows up to 10 monthly visits that are expected to be completed within 12 months unless an exception is authorized.
- Level II allows up to 22 monthly visits that are expected to be completed within 24 months unless an exception is authorized.
- Level III allows up to 22 monthly visits and are expected to be completed within 36 months unless an exception is authorized.
For more information, call the TMHP Contact Center at 800-925-9126.