(A)
General
Conditions. The MassHealth agency pays for orthodontic treatment,
subject to prior authorization, service descriptions and limitations as
described in 130 CMR 420.431. The provider must seek prior authorization for
orthodontic treatment and begin initial placement and insertion of orthodontic
appliances and partial banding or full banding and brackets prior to the
member's 21st birthday.
(B)
Definitions.
(1)
Pre-orthodontic Treatment
Examination. Includes the periodic observation of the member's
dentition at intervals established by the orthodontist to determine when
orthodontic treatment should begin.
(2)
Interceptive Orthodontic
Treatment. Includes treatment of the primary and transitional
dentition to prevent or minimize the development of a handicapping malocclusion
and therefore, minimize or preclude the need for comprehensive orthodontic
treatment.
(3)
Comprehensive Orthodontic Treatment. Includes a
coordinated diagnosis and treatment leading to the improvement of a member's
craniofacial dysfunction and/or dentofacial deformity which may include
anatomical and/or functional relationship. Treatment may utilize fixed and/or
removable orthodontic appliances and may also include functional and/or
orthopedic appliances. Comprehensive orthodontics may incorporate treatment
phases, including adjunctive procedures to facilitate care focusing on specific
objectives at various stages of dentofacial development.
(4)
Orthodontic Treatment
Visits. Periodic visits which may include, but are not limited to,
updating wiring, tightening ligatures or otherwise evaluating and updating care
while undergoing comprehensive orthodontic treatment.
(C)
Service Limitations and
Requirements.
(1)
Pre-orthodontic Treatment Examination. The MassHealth
agency pays for a pre-orthodontic treatment examination for members younger
than 21 years old, once per six months per member, and only for the purpose of
determining whether orthodontic treatment is medically necessary, and can be
initiated before the member's 21st birthday. The
MassHealth agency pays for a pre-orthodontic treatment examination as a
separate procedure (see
130 CMR
420.413) . The MassHealth agency does not pay
for a pre-orthodontic treatment examination as a separate procedure in
conjunction with pre-authorized ongoing or planned orthodontic
treatment.
(2)
Interceptive Orthodontics.
(a) The MassHealth agency pays for
interceptive orthodontic treatment once per member per lifetime. The MassHealth
agency determines whether the treatment will prevent or minimize a handicapping
malocclusion based on the clinical standards described in Appendix F of the
Dental Manual.
(b)
The MassHealth agency limits coverage of interceptive orthodontic treatment to
primary and transitional dentition with at least one of the following
conditions: constricted palate, deep impinging overbite, Class III
malocclusion, including skeletal Class III cases as defined in Appendix F of
the Dental Manual when a protraction facemask/reverse pull
headgear is necessary at a young age, craniofacial anomalies, anterior cross
bite, or dentition exhibiting results of harmful habits or traumatic
interferences between erupting teeth.
(c) When initiated during the early stages of
a developing problem, interceptive orthodontics may reduce the severity of the
malformation and mitigate its causes. Complicating factors such as skeletal
disharmonies, overall space deficiency, or other conditions may require
subsequent comprehensive orthodontic treatment. Prior authorization for
comprehensive orthodontic treatment may be sought for Class III malocclusions
as defined in Appendix F of the Dental Manual requiring
facemask treatment at the same time that authorization for interceptive
orthodontic treatment is sought. For members with craniofacial anomalies, prior
authorization may separately be sought for the cost of appliances, including
installation.
(3)
Comprehensive Orthodontics. The MassHealth agency pays
for comprehensive orthodontic treatment, subject to prior authorization, once
per member per lifetime for a member younger than 21 years old and only when
the member has a handicapping malocclusion. The MassHealth agency determines
whether a malocclusion is handicapping based on clinical standards for medical
necessity as described in Appendix D of the
Dental Manual.
Upon the completion of orthodontic treatment, the provider must take post
treatment photographic prints and maintain them in the member's dental record.
The MassHealth agency pays for the office visit, radiographs
and a record fee of the pre-orthodontic treatment examination (alternative
billing to a contract fee) when the MassHealth agency denies a request for
prior authorization for comprehensive orthodontic treatment or when the member
terminates the planned treatment. The payment for a pre-orthodontic treatment
consultation as a separate procedure does not include models or photographic
prints. The MassHealth agency may request additional consultation for any
orthodontic procedure.
Payment for comprehensive orthodontic treatment is inclusive of
initial placement, and insertion of the orthodontic fixed and removable
appliances (for example: rapid palatal expansion (RPE) or head gear), and
records. Comprehensive orthodontic treatment may occur in phases, with the
anticipation that full banding must occur during the treatment period. The
payment for comprehensive orthodontic treatment covers a maximum period of
three calendar years. The MassHealth agency pays for orthodontic treatment as
long as the member remains eligible for MassHealth, if initial placement and
insertion of fixed or removable orthodontic appliances begins before the member
reaches 21 years of age.
Comprehensive orthodontic care should commence when the first
premolars and first permanent molars have erupted. It should only include the
transitional dentition in cases with craniofacial anomalies such as cleft lip
or cleft palate. Comprehensive treatment may commence with second deciduous
molars present.
Subject to prior authorization, the MassHealth agency will pay
for more than one comprehensive orthodontic treatment for members with cleft
lip, cleft palate, cleft lip and palate, and other craniofacial anomalies to
the extent treatment cannot be completed within three years.
(4)
Orthodontic Treatment
Visits. The MassHealth agency pays for orthodontic treatment
visits on a quarterly (90-day) basis for ongoing orthodontic maintenance and
treatment beginning after the initial placement, and insertion of the
orthodontic fixed and removable appliances. If a member becomes inactive for
any period of time, prior authorization is not required to resume orthodontic
treatment visits and subsequent billing, unless the prior authorization time
limit has expired. The provider must document the number and dates of
orthodontic treatment visits in the member's orthodontic record.
(5)
Orthodontic Case
Completion. The MassHealth agency pays for orthodontic case
completion for comprehensive orthodontic treatment which includes the removal
of appliances, construction and placement of retainers and follow-up visits.
The MassHealth agency pays for a maximum of five visits for members whose
orthodontic treatment begins before their 21st
birthday, consistent with 130 CMR 420.431(A). The MassHealth agency pays for
the replacement of lost or broken retainers with prior authorization.
(6)
Orthodontic Transfer
Cases. The MassHealth agency pays for members who transfer from
one orthodontic provider to another for orthodontic services subject to prior
authorization to determine the number of treatment visits remaining. Payment
for transfer cases is limited to the number of treatment visits approved.
Providers must submit requests using the form specified by
MassHealth.
(7)
Orthodontic Terminations. The MassHealth agency
requires providers to make all efforts to complete the active phase of
treatment before requesting payment for removal of brackets and bands of a
noncompliant member. If the provider determines that continued orthodontic
treatment is not indicated because of lack of member's cooperation and has
obtained the member's consent, the provider must submit a written treatment
narrative on office letterhead with supporting documentation, including the
case prior authorization number.
(8)
Radiographs.
Payment for Cephalometric and radiographs used in conjunction with orthodontic
diagnosis is included in the payment for comprehensive orthodontic treatment
(see
130 CMR
420.423(D)) . The MassHealth
agency pays for radiographs as a separate procedure for orthodontic diagnostic
purposes only for members younger than 21 years old if requested by the
MassHealth agency.
(9)
Oral/Facial Photographic Images. The MassHealth agency
pays for digital or photographic prints, not slides, only to support
prior-authorization requests for comprehensive orthodontic treatment. Payment
for digital or photographic prints is included in the payment for comprehensive
orthodontic treatment or orthognathic treatment. The MassHealth agency does not
pay for digital or photographic prints as a separate procedure (see
130 CMR
420.413) . Payment for orthodontic treatment
includes payment for services provided as part of the pre-orthodontic treatment
examination, unless the MassHealth agency denies the prior authorization
request for interceptive or comprehensive orthodontic treatment. The MassHealth
agency pays for the pre-orthodontic treatment examination if prior
authorization is denied for interceptive or comprehensive orthodontic
treatment.
