Orthodontia is generally not an MA-covered service, but must be covered for recipients under age 21 if the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessment and evaluation indicates that it is needed. Finding exceptional circumstances in this case due to the 12-year-old petitioner’s malocclusion leading to “cuts, bruising, and swelling from accidentally biting the inside of his mouth,” ALJ Brian Schneider concluded the request in this case should be approved.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed January 25, 2025, under Wis. Stat., §49.45(5), to review a decision by the Division of Medicaid Services (DMS) to deny Medical Assistance (MA) authorization for orthodontia, a hearing was held on March 12, 2025, by telephone.
The issue for determination is whether unusual circumstances exist that warrant approval of the requested orthodontia services.
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Written submission of Tanya Zylka, RDH
Division of Medicaid Services
PO Box 309
Madison, WI 53701-0309
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a 12-year-old resident of Grant County who is eligible for MA.
- On December 24, 2024, —, by —, requested prior authorization on petitioner’s behalf for orthodontia, PA no. —. By a letter dated December 26, 2024, the DMS denied the request.
- Petitioner’s Salzmann score was 20.
- Petitioner has a sharp overbite. He accidentally bites the inside of his mouth when eating and speaking, sometimes drawing blood and causing bruising and swelling.
Discussion
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 is granted when the generic authorization criteria at §DHS 107.02(3) are met. The DMS has defined the criteria in its MA Providers Handbook, specifically related to dental issues, Topic 2909, found at www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1& sa=15&s=2&c=530&nt=Severe+Malocclusion. The policy requires a Salzmann Index score of 30, or the documentation of unusual circumstances that make the recipient’s malocclusion handicapping.
The Salzmann score is a rating of the person’s dental malocclusion, that is, how far from normal occlusion the person’s teeth are. Petitioner’s Salzmann score, as determined by the DMS dental consultant, is 20. Extenuating circumstances could be that, despite a low Salzmann, the malocclusion causes the person to have unusual difficulty eating or speaking, or the person has documented psychological problems caused by the abnormal occlusion.
There are essentially two means to determine that a request should be granted when the DMS determines a Salzmann score to be below 30. One way would be to provide evidence and argue that the Salzmann score actually is 30 or above. The other way is to provide evidence of extenuating circumstances.
There is no evidence that the DMS’s determination of the Salzmann score was incorrect. However, petitioner’s mother testified that petitioner experiences cuts, bruising, and swelling from accidentally biting the inside of his mouth. In my estimation that makes the malocclusion handicapping. While it is true that the orthodontist did not report the circumstances, my experience is that they never report unusual circumstances, and often the best evidence is from the parent who sees the child daily. I conclude that the request should be approved.
I note to petitioner that — will not receive a copy of this decision. To have the service approved, petitioner must provide a copy of this decision to his office. — must then submit a new prior authorization request, along with a copy of this decision, to receive the approved coverage.
Conclusions of Law
The request for orthodontia should be approved due to unusual circumstances that cause the malocclusion to be handicapping.
THEREFORE, it is
Ordered
That —, is hereby authorized to provide the orthodontic services as requested in PA no. —. The provider should submit a new prior authorization request along with a copy of this decision for approval.
[Request for a rehearing and appeal to court instructions omitted.]
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