Nevada Medicaid provides comprehensive healthcare coverage to eligible low-income families and individuals. The program, sometimes called Nevada Check Up or the Healthy Kids program, ensures access to necessary medical and dental services. For families seeking to correct dental alignment issues, coverage for braces is a frequent concern. The answer depends almost entirely on the recipient’s age and the medical reason for the treatment.
Eligibility and Coverage for Children
Nevada Medicaid covers orthodontic services for individuals under 21 years old, mandated by the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. This benefit requires state Medicaid programs to provide comprehensive services to treat medical and dental conditions found during screenings. To be eligible for specialized coverage, the child must meet all general Nevada Medicaid requirements.
Coverage is never automatic; the child must have a fully erupted set of permanent teeth before treatment begins. Furthermore, the proposed orthodontic care must be determined to be medically necessary by the state, ensuring funds are used for functional impairments rather than aesthetic improvements.
Defining Medical Necessity
The concept of “medically necessary” strictly governs all orthodontic coverage provided by Nevada Medicaid. The state defines necessity as treatment required to address severe malocclusions, cranio-facial anomalies, or malocclusions resulting from trauma. The goal of treatment is to relieve pain, restore dental function, prevent infection, and maintain overall dental health.
To objectively measure severity, Nevada Medicaid uses the Handicapping Labio-Lingual Deviation (HLD) Index. This standardized scoring system assigns points based on clinical measurements of bite deviations. A patient must typically achieve an HLD Index score of 30 points or higher to qualify for comprehensive orthodontic treatment.
Certain severe conditions automatically qualify, regardless of the HLD score, due to significant functional impairment. These include diagnosed cleft palate deformities, severe traumatic deviations (such as the loss of a premaxilla segment), and a deep impinging overbite where lower incisors are visibly destroying the soft tissue of the palate. In these cases, clinical evidence of tissue destruction or trauma supersedes the calculated HLD score.
If a patient scores below the 30-point threshold, a provider may request coverage through a specific Healthy Kids (EPSDT) exception process. This requires the orthodontist to submit a detailed treatment plan and clinical documentation arguing that the malocclusion causes a significant functional impairment, ensuring necessary care for children whose conditions affect their health.
The Prior Authorization and Appeal Process
Before treatment begins, the orthodontist must obtain Prior Authorization (PA) from the state or managed care organization. Following the initial evaluation, the provider submits a request using the Orthodontic Medical Necessity (OMN) Form, along with supporting diagnostic records. These records typically include X-rays, models of the teeth, and diagnostic photographs that substantiate the clinical findings and HLD score.
The state reviews this documentation to determine if medical necessity criteria are met. If the request is denied, the provider can pursue a peer-to-peer review with a Medicaid dental consultant. Alternatively, the provider can request a formal reconsideration by submitting a Prior Authorization Reconsideration Request form.
A reconsideration must be submitted within 30 calendar days of the denial and should include new clinical information. If the reconsideration is denied, the recipient’s family has the right to request a Fair Hearing or administrative review. This final administrative step involves an impartial judge reviewing the case and the state’s decision.
Orthodontic Coverage for Adults
For individuals aged 21 and older, orthodontic coverage under Nevada Medicaid is highly restricted. Adult dental services are generally optional benefits, and routine orthodontic care for alignment correction is typically excluded.
The only exceptions are when braces are an integral part of a larger, medically necessary comprehensive treatment plan. This includes situations where orthodontics are required immediately before or after medically necessary jaw surgery for severe trauma or cranio-facial reconstruction. Outside of these rare circumstances, adults must pay for the cost of braces out-of-pocket.