Court enjoins MassHealth orthodontia changes

Judge Camille Sarrouf Jr.

Dayanne v. Baker, Middlesex Superior Court, No. 2081CV01893 (J. Camille Sarrouf Jr., Order of Dec. 14, 2020) This was a case brought by an organization of orthodontists and 5 children denied orthontic treatment by MassHealth.  On Dec 14, 2020 the Court entered a preliminary injunction preventing MassHealth from implementing March and June 2020 changes it made to the index it uses to determine if orthodontic treatment is medically necessary until holding a public hearing on proposed changes.  MLRI filed an amicus brief in support of the plaintiffs.

JAN 2021 UPDATE: MassHealth issued a Transmittal Letter DEN 108 reinstating the prior standard effective Jan 15, 2021 for all prior authorization requests made after that date for children and youth under 21.  For young people whose orthodontists applied for prior authorization between Mar 25 2020 and Jan 15, 2021  were denied under the enjoined standards and have now turned 21 (the age cut off for MassHealth covered orthodontia to be approved), the Transmittal gives their orthodontists until March 31, 2021  to submit a new request for prior authorization that will be reviewed under the reinstated standards and, if approved, will be covered by MassHealth so long as treatment begins by June 30, 2021.  The Transmittal letter and the reinstated standards are attached. 

Also find attached MLRI's Memo on the Preliminary Injunction and what it means for your clients. Most important is that affected 21 year olds not miss out on chance to still get approval for orthodontia if their orthodontists request authorization by March 31, 2021, are approved and start work by June 30, 2021. 


Oct 15, 2021 UPDATE: Further revisions to criteria for determining medical necessity for orthodontia following a public hearing in July 2021. 

DEN-111: Dental Manual (Updates to 130 CMR 420.000, Subchapter 6, Appendix D, and Appendix F)