DHA Case No. MPA 207225 (Wis. Div. of Hearings and Appeals March 6, 2023) (DHS) ↓ Download PDF
Orthodontia is normally not a covered service under Wisconsin Medicaid, but if needed by a member under age 21 it can be covered (with a prior authorization) if shown to be medically necessary. It is medically necessary if the member has a Salzmann Index of at least 30 or there are “extenuating circumstances” (the malocclusion causes pain, unusual difficulty eating or speaking, or documented psychological problems). In this case, the petitioner was 10 years old, didn’t like to show his teeth, had ADHD, saw a psychiatrist monthly, and had daily oral pain. ALJ Peter McCombs concluded the orthodontia was medically necessary, acknowledging that this was a very close case but finding the mother’s testimony “credible and unrefuted.”
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Pursuant to a petition filed on December 21, 2022, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Division of Medicaid Services regarding Medical Assistance (MA), a hearing was held on February 15, 2023, by telephone.
The issue for determination is whether Petitioner is entitled to Medical Assistance coverage of orthodontic treatment.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: —, DDS (written appearance)
Division of Medicaid Services
PO Box 309
Madison, WI 53701-0309
ADMINISTRATIVE LAW JUDGE:
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a 10 year old resident of Milwaukee County.
- On or about November 8, 2022, Dr. Sara Spector with IDental, LLC filed a request for prior authorization on Petitioner’s behalf seeking Medical Assistance coverage of comprehensive orthodontic treatment, periodic orthodontic visits, and orthodontic retention (Procedure Codes D8080, D8670, and D8680).
- By written notice dated November 15, 2022, the Department informed Petitioner that coverage for the requested orthodontic treatment because the services requested did not meet ForwardHealth guidelines and did not show that services are medically necessary.
- On December 21, 2022, Petitioner filed an appeal of the denial.
Orthodontia is not an MA-covered service. Wis. Admin. Code, §DHS 107.07(4)(j). However, medical services provided to recipients under age 21 pursuant to Early and Periodic Screening, Diagnosis and Treatment (EPSDT) must be covered if the EPSDT health assessment and evaluation indicates that they are needed. 42 C.F.R. §441.56(c); Wis. Admin. Code, §DHS 107.22(4). Prior authorization for such services is required. Prior authorization is granted when the criteria set forth at Wis. Admin. Code §DHS 107.02(3) are met. Those criteria include the requirement that the requested service is a medical necessity. Wis. Admin. Code §DHS 107.22(4).
The department has developed a coverage policy to evaluate the medical necessity of orthodontic treatment. That policy, provides, in relevant part as follows:
The following criteria are considered when reviewing PA requests for orthodontia:
- A severe and handicapping malocclusion determined by a minimum Salzmann Index of 30.
- In extenuating circumstances, the dental consultant may, after comprehensive review of the case, determine that a severe handicapping malocclusion does exist, and approve the orthodontia treatment even though the Salzmann score is less than 30. . .
- If the request for orthodontic services is the result of a personality or psychological problem or condition and a member does not meet the criteria listed above, then a referral from a mental health professional is required.
Orthodontic treatment is not authorized for cosmetic reasons . . .
See ForwardHealth Provider On-line Handbook: Topic #2909. In other words, orthodontic treatment will be covered if the recipient has “a severe and handicapping malocclusion” as indicated by a minimum Salzmann Index of 30 or, in the absence of a qualifying Salzmann Index, the presence of extenuating circumstances. The Salzmann Index assessment record is a tool used by Wisconsin Medicaid to help determine whether a handicapping malocclusion is present. Id. Extenuating circumstances may be found to exist where an individual’s malocclusion causes pain, unusual difficulty eating or speaking, or documented psychological problems.
Here, the department determined that Petitioner’s Salzman score is 18, as indicated by Dr. Busby in his written submission, and there is no evidence that the department’s determination was incorrect. Petitioner’s mother, who appeared for her son at the hearing, testified that Petitioner is an adolescent, that he doesn’t like to show his teeth, and that he suffers from ADHD and sees a psychiatrist monthly. She stated that her son suffers from daily oral pain, especially with his two front teeth. The pain began about 1.5 years ago, and the family treats the pain with over the counter pain relievers.
While this is a very close case, I found the testimony of Petitioner’s mother to be credible and unrefuted. The evidence in the record is sufficient to establish that there are “extenuating circumstances” that cause orthodontic treatment to be medically necessary, as that term is defined for purposes of determining Wisconsin Medicaid coverage.
I note to the petitioner’s mother that her son’s orthodontist will not receive a copy of this decision. In order to receive the approved orthodontia, she must provide a copy of this decision to the orthodontist, who then must submit a new prior authorization request.
Conclusions of Law
The requested orthodontia is medically necessary.
THEREFORE, it is
That the petitioner’s orthodontist, is authorized to provide the orthodontia discussed in this decision. To receive reimbursement, he must submit his claim, along with a copy of this decision and a new prior authorization form to Forward Health for payment.[Request for a rehearing and appeal to court instructions omitted.]