Can You Appeal a Medicaid Denial for Braces? What You Need to Know

Receiving a Medicaid denial for braces can feel like a major setback—especially when your child clearly needs orthodontic treatment. But here’s the good news: a denial doesn’t always mean “no.” In many cases, you can appeal the decision and potentially reverse the outcome.

Medicaid has strict criteria for what it considers medically necessary treatment, but families do have rights—including the right to request a review, submit additional documentation, and make their case heard.

In this post, we’ll break down how the Medicaid appeals process works, when it makes sense to appeal, and what steps you can take to improve your chances of approval.

Why Medicaid Denies Braces in the First Place

Medicaid is designed to cover healthcare services deemed medically necessary—not cosmetic. In the context of orthodontics, this means treatment must address significant health or functional concerns such as:

• Difficulty chewing or biting
• Severe misalignment or crossbite
• Jaw development issues
• Problems with speech caused by tooth placement

Even if your child has visible crowding or gaps, Medicaid may not consider treatment necessary unless it interferes with essential functions. And because Medicaid often uses a strict scoring system, borderline cases are frequently denied.

Step 1: Carefully Review the Denial Letter

The first step in any appeal is understanding the reason for the denial. When Medicaid denies a request for braces, they’ll send a letter that includes:

• The reason(s) for the denial
• Any clinical findings or scores used in their evaluation
• Instructions for how and when to file an appeal

Pay close attention to deadlines. In New York, you generally have 60 days from the date of the denial letter to request a Fair Hearing.

Make a copy of the letter and keep it in a safe place—you’ll need the details to prepare your appeal.

Step 2: Gather Supporting Evidence

To increase the chances of a successful appeal, it’s important to build a strong case showing that your child’s condition qualifies as medically necessary. This may include:

• Updated X-rays or dental models
• Detailed notes from your child’s orthodontist or dentist
• Photos showing the impact of the misalignment
• Letters of medical necessity from healthcare providers
• Documentation of any related issues, such as speech therapy reports or notes on difficulty eating

Ask your child’s provider to review the initial submission and see what might have been missing or misinterpreted. A second opinion from another orthodontist may also uncover additional issues worth documenting.

Step 3: Request a Fair Hearing

Once you’re ready to move forward, you can file an appeal by requesting a Fair Hearing with the New York State Office of Temporary and Disability Assistance (OTDA). This is your legal right as a Medicaid recipient.

Here's what to expect:

• How to request it — You can apply online, by phone, by mail, or in person. The denial letter should include the correct contact info.
• What happens next — You'll be scheduled for a hearing (either by phone, video, or in-person), where you or your representative can present your case.
• Who can represent you — A parent or guardian, your child’s orthodontist, or even a legal advocate may speak on your behalf.
• What to bring — All relevant records, photos, letters, and anything else that supports your case

The hearing gives you a chance to explain how the denial affects your child’s health and well-being—and why the treatment should be approved.

What Happens After the Hearing?

After your Fair Hearing, a judge will review all the submitted evidence and issue a written decision—usually within a few weeks.

There are a few possible outcomes:

• Approval — The judge agrees that treatment is medically necessary and overturns the denial
• Uphold the denial — The judge finds that the original decision stands
• Request for more info — Additional documentation may be needed to reach a final decision

If your appeal is successful, Medicaid will typically cover the full cost of treatment moving forward. If not, you can still explore affordable, self-pay options (more on that below).

When Should You Consider an Appeal?

Not every denial should be appealed, but in many cases, it’s absolutely worth the effort—especially if:

• Your child has a moderate to severe orthodontic condition
• You believe there was missing or incomplete documentation
• You’ve already consulted with a specialist who recommends treatment
• Your child’s daily function or development is affected by their dental issues

Even if your first application was incomplete, a more thorough resubmission with supporting medical evidence may lead to a better outcome.

What If the Appeal Is Denied?

If the judge upholds the original decision, you still have options. Many families assume braces are unaffordable without Medicaid, but that’s not always the case.

Most orthodontic practices offer:

• Free consultations
• Monthly payment plans with zero or low interest
• Discounts for families or multiple siblings
• Sliding scale fees for qualifying income levels

You may also be able to use a Health Savings Account (HSA) or Flexible Spending Account (FSA) to help cover costs tax-free.

Even without coverage, these flexible solutions can make high-quality care manageable for families across New York.

Appeal or Not—Don't Delay Evaluation

Whether you’re planning to appeal or exploring other options, don’t delay a professional evaluation. The earlier your child sees an orthodontist, the easier it is to:

• Prevent complications
• Guide jaw growth and tooth development
• Reduce the need for more invasive procedures later
• Start treatment at the optimal time

Early intervention can save time, money, and stress in the long run—even if you’re still figuring out how to pay for care.

Support Is Available—You're Not Alone

Filing an appeal can feel like a big task, but you don’t have to go through it alone. Many orthodontic offices have experience helping families navigate Medicaid denials and can assist with gathering documents, writing letters of medical necessity, and explaining the process step by step.

Understanding your rights—and knowing how to advocate for your child—can be the difference between delayed care and a healthy, confident smile.

Need Help Navigating a Denial?

If your Medicaid application for braces was denied, we’re here to help. Families throughout East Elmhurst, Ridgewood, and Freeport turn to experienced providers who understand the appeals process and offer solutions that work—no matter your insurance status.

Braces World Orthodontics offers free consultations, flexible payment options, and support for families navigating Medicaid decisions. We’ll help you explore every path available to make sure your child gets the care they need.

Schedule your free consultation today and let’s find the right solution—together.