Dental Services for Children on DC Medicaid Cannot Be Subject to Arbitrary Limits Set by a Managed Care Organization

On December 7, 2020, Health Services for Children with Special Needs, Inc. (HSCSN), a managed care organization contracted by the District of Columbia Department of Health Care Finance to provide Medicaid services for children with special health care needs in the District,  reversed its prior decision denying coverage of a panoramic radiographic image, also known as a whole mouth dental x-ray, for one of its members with developmental delays and autism.  HSCSN had denied coverage of the whole mouth dental x-ray because it claimed that the child had reached his limit of one whole mouth dental x-ray every three years. 

Terris, Pravlik & Millian, LLP appealed the decision on behalf of the child, showing that the early and periodic, screening, diagnostic and treatment services (EPSDT) provision of the Medicaid statute (42 U.S.C. § 1396d(r)(3)) includes diagnostic dental services, such as a whole mouth x-ray, “at intervals which meet reasonable standards of dental practice” and that arbitrary limitations on such services are impermissible under federal regulations that require that each (42 U.S.C. 440.230(b)) “service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.” 

In reversing its decision, HSCSN acknowledged that Delta Dental, its dental benefit manager, has EPSDT guidelines for panoramic x-rays that recognize the need for more frequent dental x-rays for children with special needs.  See HSCSN Notification of Resolution of Appeal. 

The American Academy of Pediatric Dentistry Children recognizes that children with special health care needs “may be at an increased risk for oral diseases throughout their lifetime.” See AAPD Management of Dental Patients with Special Health Care Needs.   As explained by The National Maternal and Child Oral Health Resource Center at Georgetown University (Fact Sheet on Oral Health for Children and Adolescents with Special Health Care Needs (SHCN), Challenges and Opportunities, p. 2):

Environmental factors (e.g., cost of care, difficulty finding a dentist willing to treat children with SHCN, dental offices inaccessible to children with physical limitations) and non-environmental challenges (e.g., oral defensiveness, children’s or parent’s fear of the dentist) contribute to unmet oral health needs for children with SHCN. Children with developmental disorders, Down syndrome, autism spectrum disorders, and cerebral palsy face the most barriers to care.

The AAPD’s recommendations for children and individuals with special health care needs does not set forth any numerical limits on radiographs, recognizing that (Prescribing Dental Radiographs for Infants, Children, Adolescents, and Individuals with Special Health Care Needs, p. 1):

Because each patient is unique, the need for dental radiographs can be determined only after consideration of the patient’s medical and dental histories, completion of a thorough clinical examination, and assessment of the patient’s vulnerability to environmental factors that affect oral health.

Moreover, the AAPD recommends specific measures be taken for children with special health care needs, including, “develop[ing] an individualized oral hygiene program that takes into account the unique disability of the patient[,]” the use of sealants, and the need for “[p]atients having severe dental disease to be seen every two or three months or more if indicated.”  See AAPD Management of Dental Patients with Special Health Care Needs.  These recommendations are consistent with the District of Columbia’s Dental Periodicity Schedule, which states that the “[t]iming, selection, and frequency [of a radiographic assessment should be] determined by [the] child’s history, clinical findings, and susceptibility to oral disease.”

Therefore, a denial by a District of Columbia Medicaid Managed Care Organization of a dental x-ray or other dental service for a child with special health care needs, on the sole basis that the child has exceeded an arbitrary limit for that dental service, is improper.  Such a coverage decision can be reversed with additional information provided by your dentist or with an administrative appeal to your child’s managed care organization. 

If your child is having problems getting coverage of dental services, call our Medicaid Hotline (202-682-0578), leave a message with your name, the issue you are having, and your telephone number.  One of our paralegals will contact you as soon as possible and within one business day.  Legal services on behalf a DC Medicaid eligible child under the age of 21 who has been denied or is having problems receiving a recommended medical or dental service are free of charge.