MedicaidCoverageMedium impact
Supplement 24-16: Revised Medical Necessity Criteria for Orthodontic Treatment
New Mexico Medicaid·NM · Dentistry, Oral & Maxillofacial Surgery·Medical Policy
Effective date
Oct 1, 2024
We identified it
Jun 21, 2026
Summary
New Mexico Medicaid has revised medical necessity criteria for orthodontic treatment effective October 1, 2024. The policy establishes specific auto-qualifying conditions (cleft palate, deep overbite, crossbite, impacted cuspids, overjet >7mm) and requires a minimum HLD score of 26 points when auto-qualifiers aren't met, with comprehensive documentation requirements including diagnostic casts, x-rays, and treatment plans.
Action Required
Immediately: Dental providers must update orthodontic treatment authorization requests to include new medical necessity criteria documentation. Ensure all orthodontic cases include diagnostic casts/digital models, full mouth/panoramic x-rays, cephalometric films, diagnostic photographs, and completed HLD screening forms. Review existing cases under 21 years old against new auto-qualifier criteria (cleft palate, deep overbite touching soft tissue, crossbite with anterior teeth touching tissue or >2 teeth, impacted permanent cuspids, overjet >7mm) or ensure HLD score ≥26 points. Update prior authorization workflow to verify favorable prognosis and compliance probability documentation.