Section He-W 566.05 - Orthodontic Treatment(a) Comprehensive orthodontic treatment shall be covered for recipients under 21 years of age who demonstrate severe handicapping malocclusion, which limits function and if left untreated would result in damage to the dental structures or surrounding tissue, due to one or more of the following conditions: (1) Crowding of teeth greater than 12 mm in a single arch;(2) Deep impinging overbite with destruction of tissue;(3) Crossbite of anterior teeth with destruction of tissue;(4) Overjet greater than 9 mm;(5) Reverse overjet greater than 3.5 mm; or(6) Severe traumatic deviations demonstrated by gross pathology.(b) Interceptive orthodontic treatment shall be covered for recipients under 21 years of age who have at least one of the following conditions: (2) Deep impinging overbite with demonstration of destruction of tissue;(3) Anterior crossbite; or(4) Dentition exhibiting results of harmful habits.(c) Limited orthodontic treatment shall be covered for recipients under 21 years of age, by report, and no more than once per arch per recipient per lifetime.(d) Comprehensive and interceptive orthodontic treatment shall:(1) Each be covered once per recipient per lifetime; and(2) Require prior authorization in accordance with He-W 566.07.(e) Sealants shall be present on all permanent molars prior to the provider requesting prior authorization in (d)(2) above.(f) Any dental provider who undertakes orthodontic treatment for children with severe handicapping malocclusions shall be qualified by training and experience in accordance with Den 302.04.(g) In addition to the information required at He-W 566.07, prior authorization requests for comprehensive and interceptive orthodontic treatment shall include the following:(1) A treatment plan, which shall address and include the following: a. Diagnosis and explanation describing the nature of the severe handicapping malocclusion or functional limitation associated with the malocclusion with sufficient detail and documentation to support and demonstrate the existence of conditions described in (a)-(b) above or He-W 546.05;b. Justification for early treatment if the request is for comprehensive treatment and deciduous teeth are present or not all of the permanent teeth have erupted;c. Name of the referring dentist;d. Description of the chief complaint expressed by the referring dentist or the recipient or legal representative;e. Specific treatment objectives;f. Description of the plan for comprehensive oral care during orthodontic treatment;g. Signed statement from the provider attesting that:1. The recipient has received an oral examination and was found to be free of untreated oral disease;2. The recipient demonstrates oral hygiene habits consistent with being able to prevent inflammation and dental decay during orthodontic treatment; and3. Sealants are in place on all of the recipient's unrestored erupted molars; andh. Signed statement from the recipient or legal representative acknowledging the recipient's understanding and acceptance: 1. Of the provider's treatment plan including, but not limited to, the recipient's willingness to adhere to an oral hygiene regimen necessary to prevent inflammation and decay, to attend any scheduled appointments, and to properly wear and maintain the appliance; 2. Of the provider's right to discontinue treatment for non-compliance, including, but not limited to, the recipient's failure to adhere to oral hygiene expectations, missed appointments, and failure to properly wear or maintain appliances;3. That the Title XIX program will not pay for the cost of orthodontic treatment beyond the recipient's 21st birthday; and4. That the Title XIX program will not pay for the cost of orthodontic treatment more than once per recipient per lifetime if treatment is terminated due to non-compliance with the treatment plan as documented by the provider;(2) Diagnostic model taken within 30 days of submitting the prior authorization request;(3) Treatment cost estimate;(4) Except as allowed by (h) below, radiographs that are current and of adequate quality to allow for an accurate diagnosis of the malocclusion; and(5) Assurance that the requested treatment is the least restrictive, most cost-effective treatment for the malocclusion.(h) When requesting interceptive treatment, photographs may be submitted in lieu of radiographs, provided the photographs clearly demonstrate the criteria being considered for approval.(i) Banding shall occur within 60 days of the receipt of the prior authorization approval.(j) Comprehensive orthodontic treatment shall be covered only if the recipient adheres to the treatment plan of care specified at (g)(1) above.(k) Treatment may be terminated by the provider for non-compliance, including, but not limited to, the recipient's failure to adhere to oral hygiene expectations, missed appointments, and failure to properly wear or maintain appliances.(l) Providers shall supply the department with treatment progress reports at the following intervals: (1) A progress report immediately following the 12th month of treatment, including a description of recipient compliance with the provider's treatment plan and a report of objectives achieved to date;(2) A final treatment report, including diagnostic models or post treatment photographs of the dentition in centric relation from center, right and left sides, submitted at the conclusion of treatment which demonstrate that the treatment goals have been met; and (3) Immediate report of any patterns of non-compliance, if applicable.N.H. Admin. Code § He-W 566.05
(See Revision Note at chapter heading He-W 500); ss by #5639, eff 6-17-93; ss by #7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by #9902, eff 6-1-11
Amended by Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12782, Effective 5/21/2019, Expires 11/18/2019.Amended by Volume XL Number 2, Filed January 9, 2020, Proposed by #12937, Effective 12/7/2019, Expires 12/7/2029.