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Decision by the Division of Public Health to deny request for Medicaid coverage


In re:
DCIS No. Redacted
Redacted, a minor

Appearances:
Redacted, Claimant's Legal Guardian
Redacted, Claimant's Legal Guardian
David Michalik, Senior Administrator, Division of Social Services
Dr. Gregory B. McClure, Dental Director, Division of Public Health

I.

Redacted ("Claimant"), through her legal guardians Redacted, opposes a decision by the Division of Public Health (DPH) to deny her request for Medicaid coverage of orthodontic care.

DPH contends that while orthodontic care may be available under the Medicaid Early Periodic Screening, Diagnostic and Treatment Services (EPSDT) program, the Claimant's dental profile was not one consisting of a handicapping malocclusion, as required under the Center of Medicare and Medicaid's State Medicaid Manual, Part 5, Section 5124(B)(2)(b).

II.

By notice dated October 20, 2004, DPH denied the Claimant's request for Medicaid Coverage of Orthodontic Care. (Exhibit 4)

The Claimant filed a request for a fair hearing on November 22, 2004, attaching documents not previously reviewed by DPH, because they were not provided to DPH. (Exhibit 3)

The Claimant was notified by letter dated December 17, 2004, that a fair hearing would be held on February 1, 2005. The hearing was conducted on that date in New Castle, DE.

This is the decision resulting from that hearing.

III.

The Division of Social Services of the Department of Health and Social Services operates the Delaware Medical Assistance Program (DMAP). DPH is a State actor/contractor and manages certain of the program's operations, including EPSDT.

Jurisdiction for this hearing is pursuant to §5304 of the Division of Social Services Manual (DSSM). Under §5304:

an opportunity for a hearing will be granted to any applicant who requests a hearing because his/her claim is denied and to any recipient who is aggrieved by any action of the Division of Social Services. Only issues described in the notice of action sent to the appellant or issues fairly presented in the appellant's request for a fair hearing or in the Division's response in its hearing summary may be presented for the hearing officer's review at the hearing.

IV.

Claimant's guardians sought coverage for orthodontic work approximately one year prior to the hearing. At that time, the Claimant's guardians provided all requested information and requested that their treating dentists provide complete documentation and dental models to DPH. Redacted testified that they had believed that all information had been provided, and were then informed that due to a lack of funding, a determination on the case would not be forthcoming. On October 20, 2004, DPH issued a notice to Redacted, denying coverage for the requested orthodontic care. (Exhibit 4)

By letter date-stamped November 22, 2004, the Claimant's legal guardians requested a fair hearing, and enclosed documentation from Amanda's treating dentists that they thought had already been provided to DPH, but that had, in fact, never been submitted. (Exhibit 3)

DPH testified that when the received the request for a hearing, along with additional documents, they reviewed those documents prior to issuing their Fair Hearing Summary ("FHS") (Exhibit 1), which was sent to the Redacted. The FHS clearly indicates that prior to the hearing, DPH had a chance to review the additional documentation, and determined that it had no additional bearing on the case. They testified that they came to that conclusion because the majority of the additional information provided only supported the issue of teeth crowding, which they had already determined would receive the highest point value on the Delaware Special Dental Orthodontic Evaluation form. DPH further testified that they utilize this form, derived from the California Modification of the Handicapping Labiolingual Deviation Index ("HLD CalMod"), to evaluate all requests for orthodontic care relating to handicapping malocclusions. DPH explained that in order to be a covered service, a score of 26 is needed on the HDL CalMod Index. Absent a score of 26 on this Index, an applicant could only receive services if there were an exception warranting service.

In this case, Dr. Gregory B. McClure, Dental Director for DPH, testified that he performed a review of the case records and concluded that Redacted dental condition should receive a score of 21, five (5) points shy of the required 26 point threshold. Dr. McClure also testified that Redacted does suffer from a malocclusion (which is a deviation from the norm), he also testified that her deviation was not so extreme to be considered a handicapping malocclusion. Importantly, he noted that Redacted had received the total points available for teeth crowding, and that the additional documentation provided by Redacted did not warrant an exception to change any of the other criteria reviewed for scoring purposes under the HDL CalMOd Index. Dr. McClure also testified that all of the other criteria reviewed and used for scoring were actual measurements, and left no room for subjectivity. He did admit, however, that the measurements and models that he reviewed were about at least a year old, and that is was possible, that during the interval from initial request for coverage to the time of actual denial, a change in Redacted score could be possible due to changes in the measurements needed to complete the Index.

While the regulations are clear regarding coverage for orthodontic care and the requirement of one having a handicapping malocclusion under EPSDT Section 5124(B)(2)(b), the record before me does not fully substantiate that Redacted did not have a score of 26 on the Index at the time of the determination to deny coverage. At best, a review of the documents showed that a year ago, Redacted did not fit the profile for coverage. Absent additional dental models and measurements that are current, DPH made a determination that is not necessarily consistent with Redacted dental condition at this time.

Accordingly, the decision to deny Redacted orthodontic care cannot be sustained on the record before me. However, neither can a decision to provide care be determined from this record.

V.

For these reasons, the decision of the Division of Public Health to deny the Claimant's request for orthodontic care is REVERSED. The case is REMANDED to DPH to obtain current dental models and other relevant documentation relating to the condition of Redacted teeth, and her surrounding and supporting structures related thereto.

Date: March 14, 2005

MICHAEL L. STEINBERG
HEARING OFFICER

THE FOREGOING IS THE FINAL DECISION OF THE DIVISION OF SOCIAL SERVICES

POSTED
MLS/vmd

cc:
Redacted
David Michalik, DSS
Dr. Gregory B. McClure, DPH

EXHIBITS FILED IN OR FOR THE PROCEEDING

  • EXHIBIT #1 - Copy of DSS Hearing Summary consisting of two (2) pages date-stamped December 7, 2004.
  • EXHIBIT #2 - Copy of Delaware Special Dental Orthodontic Evaluation, consisting of one (1) page.
  • EXHIBIT #3 - Copy of the Claimant's request for a fair hearing date-stamped September 22, 2004, consisting of 19 pages.
  • EXHIBIT #4 - Copy of letter denying benefits, dated October 20, 2004, consisting of one (1) page.


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