Does Denti-Cal Cover Braces and How to Qualify

Denti-Cal, California’s Medicaid dental program, offers services to provide oral healthcare access for eligible low-income individuals and families. This article clarifies Denti-Cal’s coverage for orthodontic treatment, specifically braces, outlining the conditions for medical necessity and the required authorization procedures.

Scope of Orthodontic Coverage

Denti-Cal provides orthodontic coverage only when treatment is medically necessary, distinguishing it from purely cosmetic procedures. Braces must address a significant health issue rather than solely improve appearance. Orthodontic benefits are primarily available for beneficiaries under 21 years of age, with eligibility ending once a person reaches their 21st birthday.

The program covers severe conditions leading to functional impairment, such as difficulties with chewing or speech, or significant oral health problems. Qualifying conditions include:
Severe deep impinging overbite that damages soft tissue
Crossbite causing similar tissue damage
Severe overjets greater than 9 millimeters
Cleft palate deformities
Craniofacial anomalies

Meeting Medical Necessity Criteria

A qualified orthodontist assesses whether a patient’s condition meets Denti-Cal’s medical necessity criteria. This assessment involves gathering diagnostic records, which include X-rays, dental models, and photographs. These records provide a view of the patient’s oral structure and the severity of the malocclusion.

Denti-Cal utilizes specific scoring systems, such as the Handicapping Labio-Lingual Deviations (HLD) index with California modifications, to quantify the condition’s severity. A score of 26 points or more on the HLD index indicates the malocclusion is severe enough for coverage. The HLD index measures:
Overjet
Overbite
Mandibular protrusion
Open bite
Ectopic eruption
Anterior crowding

Certain severe conditions can automatically qualify for orthodontic services, even without meeting the HLD index score threshold. These include severe traumatic deviations, cleft palate deformities, or craniofacial anomalies. The underlying issue must cause significant functional impairment or pose a clear risk to the patient’s long-term oral health, rather than being a mere aesthetic concern.

The Prior Authorization Submission Process

Once an orthodontist determines a patient’s condition meets medical necessity criteria, their office manages the prior authorization request. This is a mandatory step, as all orthodontic services require approval from Medi-Cal Dental before treatment can begin. Providers are advised not to initiate treatment until this authorization is received.

The submission package must be comprehensive, including a proposed treatment plan and detailed justification that aligns with medical necessity criteria. This justification is supported by diagnostic records, such as study models, X-rays, and photographs, collected during the initial assessment. Specific forms, like the HLD Index score sheet, are also included to document the condition’s severity.

After submission, patients should anticipate a waiting period while Medi-Cal Dental reviews the request. The program may request additional information or clarification to aid in their decision-making process. The thoroughness of the initial submission can help streamline this review.

Navigating Outcomes and Next Steps

Following review, the prior authorization request will result in either an approval or a denial. If approved, the patient can schedule orthodontic treatment. The approval notice will detail the specific scope of services covered, and patients must maintain Denti-Cal eligibility throughout the entire course of treatment.

If the prior authorization request is denied, beneficiaries have the right to appeal the decision. The initial step in an appeal is to review the Explanation of Benefits (EOB) statement, which outlines the specific reasons for the denial. This information is crucial for formulating an effective appeal.

To support an appeal, patients should gather:
Clinical notes
Treatment plans
Diagnostic images from their orthodontist
Any previous correspondence

Appeals must be submitted in writing within 30 to 60 days of receiving the denial notice. A “Fair Hearing” or Independent Medical Review (IMR) may be an option, offering an impartial review of the medical decision.