Medicaid Coverage for Orthodontic Procedures

by | Published on Oct 27, 2022 | Podcasts, Dental Billing & Coding (P) | 0 comments

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Podcast Highlights

00:50 What is Medical Necessity?

01:20 Brace Coverage for a Child

In today’s podcast, Amber Darst, one of our Solutions Managers, discusses the Medicaid coverage for orthodontic procedures.

Read Transcript

Hi, this is Amber Darst, Solutions Manager for Managed Outsourced Solutions and for this podcast, I’ll be discussing a bit on Medicaid coverage for orthodontic procedures.

Medicaid programs are predominantly aimed at covering dental services for children and youth under the age of 21. But there are few states that provide adult dental benefits as well. Poor oral health is a leading cause of concern and is particularly impacting people with lower incomes. Taking this into consideration, Medicaid provides reimbursement for dental services such as check-ups, cleanings, fillings, and extractions. However, when it comes to orthodontic benefits, the coverage is restricted to only when there is a medical necessity.

00:50 What is Medical Necessity?

So, what does medical necessity mean?

Medical necessity is an important factor for a patient to be eligible for Medicaid-reimbursable treatment services. The definitions of medical necessity are based on certain constraints and they do vary from state to state. Some states reduce Medicaid costs by having cost restrictions in place. This is done by limiting patients to the least expensive treatment available.

01:20 Brace Coverage for a Child

However, if braces are deemed a medical necessity for a child, they will be covered under the Medicaid program. And orthodontists or dentists confirms if braces are medically necessary for the child, here are some of the considerations that are used to determine medical necessity: if the patient has a cleft palate, or structural jaw issues making it difficult to open the mouth, issues with eating or chewing normally or issues with speech impediments from tooth or jaw problems, any extreme underbite, crossbite, or overbite, overjet teeth, impacted teeth with an eruption, or missing teeth due to hereditary conditions such as hypodontia.

The services provided by dental practices must be documented correctly to eliminate claim denials. An experienced dental billing company can assist with ensuring timely and accurate claim submissions, keeping a smooth, steady flow of revenue for your practice. For more on this topic plus a list of the relevant CDT codes associated with this podcast, please refer to the attached article.

(Dental anesthesia procedure

  • D9222: Deep sedation/general anesthesia -first 15 minutes
  • D9223: Deep sedation/general anesthesia -each 15-minute increment
  • D9239: Intravenous moderate (conscious) sedation/analgesia-first 15 minutes
  • D9243: Intravenous moderate (conscious) sedation/ analgesia- each 15-minute increment

Dental braces – Orthodontic codes

  • D8210: Removable appliance therapy
  • D8220: Fixed appliance therapy
  • D8060: Interceptive orthodontic treatment of the transitional dentition
  • D8080- Comprehensive orthodontic treatment of the adolescent dentition)

And that’s all on this. Thanks for listening in.

Amber Darst

Amber Darst is our Solutions Manager in the Healthcare Division, Practice and RCM. With a rich background in dental services, her expertise ranges from insurance coordination to office management.

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