SECTION 14 - SPECIAL DOCUMENTATION REQUIREMENTS 14.1 CERTIFICATE OF MEDICAL NECESSITY...2 14.2 OPERATIVE REPORT...2 14.2.A PROCEDURES REQUIRING A REPORT...2 14.3 PRIOR AUTHORIZATION REQUEST...2 14.3.A PROCEDURES REQUIRING PRIOR AUTHORIZATION...3 14.3.B PRIOR AUTHORIZATION FOR ORTHODONTICS...3 14.3.C PRIOR AUTHORIZATION FOR DENTURES (TEXT DEL. 8/06)...3 14.3.D HEALTHY CHILDREN AND YOUTH (TEXT DEL. 8/06)...3 14.4 THE HANDICAPPING LABIO-LINGUAL DEVIATION (HLD) INDEX...3 14.4.A GUIDELINES AND RULES FOR APPLYING THE HLD INDEX...4 14.4.B INSTRUCTIONS FOR THE HLD INDEX MEASUREMENTS...5 1
SECTION 14 SPECIAL DOCUMENTATION REQUIREMENTS Program limits may require prior authorization or medical necessity. Refer to Section 14.3 for special dental instructions for requesting prior authorization. The MO HealthNet Program has requirements for other documentation when processing claims under certain circumstances. Refer to Sections 15, Billing Instructions, and Section 16, Medicare/MO HealthNet Crossover Claims, for further information. Refer to Sections 1-11 and Section 20 for general program documentation requirements. Please be aware that when a specific procedure requires an attachment and a modifier (such as 50 bilateral) is used, the attachment remains a positive requirement and must also be attached to the procedure that has the modifier. 14.1 CERTIFICATE OF MEDICAL NECESSITY A Certificate of Medical Necessity form is required any time services exceed policy limitations or specific policy documentation is required, but because of an unusual or exceptional situation, the form(s) can not be completed, or is/are inappropriate for the situation. For example, all nonemergency services provided out-of-state require a Prior Authorization Request. In an emergency situation, a service performed out-of-state that normally requires a Prior Authorization Request can be submitted with a completed Certificate of Medical Necessity form. Dentures may never be provided with a Certificate of Medical Necessity form. 14.2 OPERATIVE REPORT An operative or special descriptive report (as indicated by the procedure) may be requested by the State Dental/Orthodontic Consultant to assist in determining the exact procedure(s) performed, and subsequent reimbursement. Certain procedure codes always require a report with each claim submission. 14.2.A PROCEDURES REQUIRING A REPORT Refer to Section 19 of the for codes that always require a report. 14.3 PRIOR AUTHORIZATION REQUEST Under the MO HealthNet Program, certain covered services and equipment require prior approval by the MO HealthNet Division. Prior authorization is used to promote the most efficient and appropriate use of available services. See Section 8 for general information about requesting prior authorization and using the Prior Authorization Request form. Reference Section 13.13.A for dental prior authorization guidelines. 2
When requesting prior authorization of a currently noncovered service through the Healthy Children and Youth (HCY) Program, indicate HCY REQUEST in the description Field #21. Approval or denial is indicated line by line on the Prior Authorization Request form in the box to the right of Section III. Also in this box the consultant indicates the allowed amount if applicable, or if the procedure requires manual pricing. At the bottom of the form, the consultant explains any denials or makes notations as needed, referencing specific procedure codes and descriptions, or the specific line number (1 through 12). The consultant also indicates the date the services are authorized to begin (this is normally the date the consultant review is completed). Finally, the consultant initials the form. Claims are not reimbursed unless prior authorization was obtained before the date of service. 14.3.A PROCEDURES REQUIRING PRIOR AUTHORIZATION Orthodontics is an example of a procedure that always requires prior authorization, regardless of the participant s place of residence, or where the services are to be provided. Procedure codes that require prior authorization are listed in Section 19 of the. 14.3.B PRIOR AUTHORIZATION FOR ORTHODONTICS When requesting prior approval for the provision of extended orthodontic treatment, providers should pay particular attention to Fields #19 From and #20 Through on the Prior Authorization Request form. These fields should reflect the anticipated orthodontic treatment time required. If the service is approved, this information is reflected on the prior authorization file. The approved amount is authorized on the Prior Authorization Request form when requesting orthodontics, and when the procedure requires manual pricing this amount is also reflected on the prior authorization file. 14.3.C PRIOR AUTHORIZATION FOR DENTURES (text del. 8/06) 14.3.D HEALTHY CHILDREN AND YOUTH (text del. 8/06) 14.4 THE HANDICAPPING LABIO-LINGUAL DEVIATION (HLD) INDEX The Omnibus Budget Reconciliation Act of 1989 (OBRA '89) mandated that Medicaid covered services be provided for individuals under the age of 21 when service is medically necessary, regardless of whether the service is covered by the State Medicaid Plan. Individuals under age 21 with ME code 80 are not able to access expanded HCY services. 3
Orthodontic procedures are covered as expanded HCY services but require prior approval. Orthodontic procedures are only approved for the most handicapping malocclusions. A handicapping malocclusion is a condition that constitutes a hazard to the maintenance of oral health and interferes with the well-being of the patient by causing impaired mastication, dysfunction of the temporomandibular articulation, susceptibility to periodontal disease, susceptibility to dental caries and impaired speech due to malposition of the teeth. Assessment of the most handicapping malocclusion is determined by the magnitude of the following variables: degree of malalignment, missing teeth, angle classification, overjet, overbite, openbite and crossbite. Since a case must be handicapping to be accepted for orthodontic care, participants whose molars and bicuspids are in good occlusion seldom qualify. Crowding alone is usually aesthetic in spite of functional consideration. An anteroposterior problem must be one full cusp in magnitude in order to be considered. Requests for services for cosmetic purposes do not receive prior authorization approval. The Handicapping Labio-Lingual Deviation (HLD) Index is used to determine the medical necessity for orthodontic services. Providers may use the HLD Index to make an in office determination regarding the patient's degree of malocclusion, and may submit this determination along with the PA Request. The PA Request form must be submitted along with study models, photographs and x-rays. Only those cases that score 28 points or more on the HLD Index or those that qualify under an exception are granted. This is not to say that cases that score less than 28 points do not represent some degree of malocclusion, but simply that the severity of the malocclusion does not qualify for coverage under the MO HealthNet program. It is important to note that when scoring the HLD Index, the provider is not diagnosing malocclusion but simply measuring and/or noting the presence or absence of certain key indicators. 14.4.A GUIDELINES AND RULES FOR APPLYING THE HLD INDEX 1. Orthodontic benefits are available to eligible beneficiaries with handicapping malocclusions who are age 20 and under with permanent dentition, except in cleft palate cases or with mixed dentition when the beneficiary has reached his/her thirteenth (13 th ) birthday. 2. Study models must be of diagnostic quality. To meet diagnostic requirements, study models must be properly poured and adequately trimmed with no large voids or positive bubbles present. Dental study models should stimulate centric occlusion of the patient when models are placed on their heels. Study models that do not meet the diagnostic requirements described above are not accepted. 3. Only teeth that have erupted and are visible on the study models should be considered, measured, counted and recorded. 4
4. In cases submitted for deep impinging bite with tissue destruction, the lower teeth must be clearly touching the palate and tissue indentations or other evidence of soft tissue destruction must be visible on the study models. 5. Either of the upper central incisors must be used to measure overjet, overbite (including reverse overbite), mandibular protrusion, and open bite. Do not use the upper lateral incisors or cuspids for these measurements. 6. The following definitions and instructions apply when using the HLD Index to identify ectopic eruptions: Examples of ectopic eruption (and ectopic development) of teeth include: When a portion of the distal root of the primary second molar is resorbed during the eruption of the first molar Transposed teeth Teeth in the maxillary sinus Teeth in the ascending ramus of the mandible Situations where teeth have developed in locations other than the dental arches In all other situations, teeth deemed to be ectopic must be more than 50% blocked out and clearly out of the dental arch In cases of mutually blocked-out teeth only one is counted 14.4.B INSTRUCTIONS FOR THE HLD INDEX MEASUREMENTS Procedure: 1. Position the patient s teeth in centric occlusion 2. Record all measurements in the order given and round off to the nearest millimeter 3. Enter the score 0 if condition is absent 4. The use of a recorder (assistant or hygienist) is recommended Conditions: 1. Cleft palate deformities automatic qualification; however, if the deformity cannot be demonstrated on the study model, the condition must be diagnosed by properly credentialed experts and the diagnosis must be supported by documentation. If present, enter an X and score no further. 2. Deep impinging overbite tissue destruction of the palate must be clearly visible in the mouth. On study models, the lower teeth must be clearly touching the palate and the tissue indentations or evidence of soft tissue destruction must be clearly visible. If present, enter an X and score no further. 5
3. Crossbite of individual anterior teeth destruction of soft tissue must be clearly visible in the mouth and reproducible and visible on the study models. Gingival recession must be at least 1½ mm deeper than the adjacent teeth. If present, enter an X and score no further. In the case of a canine, the amount of gingival recession should be compared to the opposite canine. 4. Severe traumatic deviations these might include, for example, loss of a premaxillary segment by burns or accident, the result of osteomyelitis, or other gross pathology. If present, enter an X and score no further. 5. Overjet this is recorded with the patient s teeth in centric occlusion and is measured from the labial surface of a lower incisor to the labial surface of an upper central incisor. Measure parallel to the occlusal plan. Do not use the upper lateral incisors or cuspids. The measurement may apply to only one tooth if it is severely protrusive. Reverse overjet may be measured in the same manner. Do not record overjet and mandibular protrusion (reverse overjet) on the same patient. (Note: If the overjet is greater than 9 mm or reverse overjet is greater than 3.5 mm enter an X and score no further.) 6. Overbite a pencil mark on the tooth indicating the extent of the overlap assists in making this measurement. Hold the pencil parallel to the occlusal plane when marking and use the incisal edge of one of the upper central incisors. Do not use the upper lateral incisors or cuspids. The measurement is done on the lower incisor from the incisal edge to the pencil mark. Reverse overbite may exist and should be measured on an upper central incisor from the incisal edge to the pencil mark. Do not record overbite and open bite on the same patient. Enter the measurement in millimeters. 7. Mandibular (dental) protrusion or reverse overjet measured from the labial surface of a lower incisor to the labial surface of an upper center incisor. Do not use the upper lateral incisors or cuspids for this measurement. Do not record mandibular protrusion (reverse overjet) and overjet on the same patient. The measurement in millimeters is entered on the score sheet and multiplied by five (5). 8. Open bite measured from the incisal edge of an upper central incisor to the incisal edge of a lower incisor. Do not use the upper lateral incisors or cuspids for this measurement. Do not record overbite and open bite on the same patient. The measurement in millimeters is entered on the score sheet and multiplied by four (4). 9. Ectopic eruption count each tooth excluding third molars. Enter the number of teeth on the score sheet and multiply by three (3). If condition No. 11, anterior crowding, is also present with an ectopic eruption in the anterior portion of the mouth, score only the most severe condition (the condition represented by the most points). DO NOT SCORE BOTH CONDITIONS. 10. Anterior crowding anterior arch length insufficiency must exceed 3.5 mm. Mild rotations that may react favorably to stripping or mild expansion procedures are not to be 6
scored as crowded. Enter five (5) points for a maxillary arch with anterior crowding and five (5) points for a mandibular arch with anterior crowding. If condition No. 10, ectopic eruption, is also present in the anterior portion of the mouth, score only the most severe condition (the condition represented by the most points). DO NOT SCORE BOTH CONDITIONS. 11. Labio-lingual spread use a Boley gauge (or disposable ruler) to determine the extent of deviation from a normal arch. Where there is only a protruded or lingually displaced anterior tooth, the measurement should be made from the incisal edge of that tooth to a line representing the normal arch. Otherwise, the total distance between the most protruded tooth and the most lingually displaced adjacent anterior tooth is measured. In the event that multiple anterior crowding of teeth is observed, all deviations should be measured for labio-lingual spread but only the most severe individual measurement should be entered on the on the score sheet. Enter the measurement in mm. 12. Posterior crossbite this condition involves one or more posterior teeth, one of which must be a molar. The crossbite must be one in which the maxillary posterior teeth involved may be palatal to normal relationships or completely buccal to the mandibular posterior teeth. The presence of posterior crossbite is indicated by a score of four (4) on the score sheet. The provider is encouraged to score the case and exclude any case that obviously would not qualify for treatment. Please note the first 5 items include exceptions to the 28 point requirement. Upon completion of the HLD Index score sheet, review all measurements and calculations for accuracy. END OF SECTION TOP OF PAGE 7