Nevada Medicaid covers braces only for eligible children when the need is determined to be medical, not cosmetic. This coverage is provided under the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which mandates comprehensive services for those under the age of 21. Orthodontic treatment is not automatically approved and requires a rigorous process to prove that the malocclusion significantly impairs the child’s health or function. The state’s program ensures that all necessary dental services, including orthodontia, are available for qualifying young people.
Eligibility Requirements for Orthodontic Services
The foundational requirement for orthodontic coverage through Nevada Medicaid is that the recipient must be under 21 years of age. This age limit is a strict mandate of the federal EPSDT program, which is designed to provide comprehensive healthcare for children and adolescents. Eligibility is tied to enrollment in Nevada Medicaid or Nevada Check Up, the state’s Children’s Health Insurance Program (CHIP).
These programs have specific income and residency requirements that must be met for underlying health coverage. The EPSDT benefit acts as an assurance that once a child is enrolled, they will receive necessary dental services, including braces, if the condition warrants it. Parents can contact a Medicaid dental provider directly for an orthodontic evaluation; a referral from a general dentist is not strictly necessary.
Defining the Medical Necessity Standard
Medicaid coverage for braces is strictly limited to cases deemed “medically necessary,” never for cosmetic reasons. Medical necessity is defined by the severity of the malocclusion and its impact on the patient’s oral health, function, or overall well-being. Nevada Medicaid uses specific, objective criteria to quantify this need, utilizing a set of Medically Necessary Orthodontic Automatic Qualifying Conditions.
These automatic qualifying conditions include severe functional impairments:
- A substantial overjet of 9 millimeters or more, or a reverse overjet of 3.5 millimeters or more.
- A lateral or anterior open bite of 2 millimeters or more across at least four teeth per arch.
- An impinging overbite where the lower teeth are causing tissue destruction in the opposing soft tissue.
- Severe structural issues like cranio-facial anomalies or malocclusions caused by trauma.
- Significant crowding or spacing of 10 millimeters or more in either arch.
If a child does not meet an automatic qualifying condition, a provider may request an EPSDT exception by demonstrating a functional impairment. This request must thoroughly document the medical need, often including functional factors like difficulty with chewing or speech. In rare cases, documentation from a Qualified Mental Health Practitioner may verify a psychological need directly related to the malocclusion.
The Prior Authorization and Approval Process
Before any orthodontic treatment can begin, the Medicaid-enrolled child must obtain a Prior Authorization (PA) from Nevada Medicaid’s fiscal agent. The process starts with finding a Medicaid-participating orthodontist who assesses the condition and submits the necessary request. Orthodontic services are covered through the Fee-for-Service (FFS) benefit plan, and all PA requests must be submitted directly to Nevada Medicaid, not a managed care organization.
The orthodontist compiles a comprehensive package of documentation using the Orthodontic Medical Necessity (OMN) Form. This package requires diagnostic photographs that clearly demonstrate the condition’s severity, along with dental models and X-rays. The provider must also certify that the recipient has completed all other necessary dental work and maintains good oral hygiene, as poor hygiene can lead to denial.
Once submitted, the Medicaid dental contractor reviews the application to determine if medical necessity standards have been met. If the request is denied, the provider has avenues for appeal. These include submitting a written request for reconsideration with additional medical justification or requesting a peer-to-peer review with a Nevada Medicaid dental consultant.
Adult Coverage and Restrictions
Nevada Medicaid coverage for orthodontic services ceases once a beneficiary reaches the age of 21. The comprehensive dental benefit, including braces, is mandated only for individuals under 21 through the EPSDT program. For adults aged 21 and older, dental services are optional, limited to emergency extractions, palliative care, and prosthetics like dentures or partials under certain guidelines.
Orthodontic treatment for adults is not covered for the correction of malocclusion, even if severe. The only narrow exception is if the orthodontic procedure is an integral and unavoidable part of a covered surgical procedure to correct a severe medical condition, such as a craniofacial anomaly. These instances are rare and require extensive prior authorization, meaning coverage for braces is generally unavailable to adult beneficiaries.