Finding out that your Medicaid application for orthodontic treatment has been denied can be disheartening—especially when you know your child could benefit from braces. But a denial doesn't necessarily mean the end of the road. There are clear steps you can take to better understand the decision, explore your options, and still get the care your child needs.
In this guide, we’ll walk you through the common reasons Medicaid applications are denied, what you can do to appeal the decision, and what affordable alternatives exist if coverage isn’t granted.
Why Medicaid Denies Orthodontic Applications
While Medicaid does cover orthodontic treatment for children in many cases, it only approves care that is considered “medically necessary.” This means that cosmetic reasons—like mild crowding or small gaps—typically don’t qualify for coverage.
Here are some common reasons Medicaid may deny an application for braces:
- Bite misalignment — When the teeth don’t line up properly, but the issue is mild and doesn’t interfere with speech or eating
- Crowding or spacing — If the crowding is not severe enough to cause long-term dental problems
- Lack of documentation — Missing X-rays, dental records, or referral forms can result in an automatic denial
- Age limits — In many states, including New York, orthodontic coverage is only available to children under a certain age
- Determination of “cosmetic” needs — Even if there are visible concerns, Medicaid may determine that treatment is not medically essential
Understanding the specific reason for the denial is the first step toward deciding what to do next.
Step 1: Review the Denial Letter Carefully
Medicaid will send a letter outlining the reason(s) your application was denied. Read it thoroughly and look for:
- Specific denial codes or language explaining the decision
- Missing documents that may have led to an incomplete application
- Instructions for appeals or next steps if you wish to challenge the decision
Make note of deadlines—there is typically a limited window (often 60 days) to file an appeal.
Step 2: Contact Your Orthodontist or Referring Dentist
If you submitted your application through an orthodontist or general dentist, reach out to their office for help. They can:
- Explain the clinical findings they submitted
- Help determine whether additional documentation could strengthen your case
- Assist with resubmitting or appealing the application
Sometimes, the issue is as simple as an error in the paperwork or a missing X-ray.
Step 3: Consider Filing an Appeal
If you believe your child’s orthodontic needs qualify for coverage, you may be able to appeal the denial. The appeals process varies by state, but in New York, here’s what it typically involves:
- Requesting a Fair Hearing — This is your opportunity to present your case to an administrative law judge
- Submitting additional evidence — This may include updated X-rays, letters from dental professionals, or new clinical notes
- Attending the hearing — These may be held in person, by phone, or virtually
It’s a good idea to involve your child’s dentist or orthodontist in this process—they can provide critical documentation to support your appeal.
Step 4: Explore Other Coverage Options
If your appeal is unsuccessful or if you're ineligible to file one, you may still have other options to access care.
Some families explore:
- CHIP (Children’s Health Insurance Program) — In some cases, CHIP may cover orthodontic treatment for children who don’t qualify under Medicaid
- Private dental insurance — Certain private plans offer partial orthodontic coverage; check with your provider for eligibility and limitations
- Health savings accounts (HSAs) or flexible spending accounts (FSAs) — These tax-advantaged funds can sometimes be used to pay for orthodontic treatment
Be sure to compare each option carefully, especially in terms of monthly premiums, deductibles, and treatment limits.
Step 5: Look Into Affordable Self-Pay Options
Even without Medicaid coverage, affordable orthodontic care may still be within reach. Many practices offer flexible options to help make treatment accessible, including:
- Low monthly payment plans — Spread out the cost of treatment with no or low interest financing
- Family discounts — Practices may offer price breaks for multiple family members
- Sliding scale pricing — Some offices adjust fees based on household income
- Free initial consultations — Many orthodontic offices provide free evaluations, allowing you to explore options without commitment
Don't assume that private treatment is out of your budget—many families are surprised to find that flexible payment plans make care manageable.
Understanding the Importance of Treatment
Even if Medicaid determines that braces aren’t “medically necessary,” orthodontic care can still have a lasting impact on your child’s health and confidence. Braces can:
- Prevent more serious dental issues in the future
- Improve speech, chewing, and oral hygiene
- Boost self-esteem and emotional well-being
Delaying treatment can allow issues to worsen, leading to more complex (and costly) problems later on. Seeking care sooner rather than later often provides the best outcome—both clinically and financially.
When to Seek a Second Opinion
If you're unsure about your child's treatment needs—or if you're feeling discouraged after a denial—consider scheduling a second opinion with a trusted orthodontic provider.
A second evaluation can:
- Clarify whether treatment is clinically necessary
- Provide a different interpretation of the same dental records
- Introduce new options that weren’t previously discussed
You deserve to feel confident in the next steps for your child's smile, and sometimes a fresh perspective makes all the difference.
Your Next Step Toward a Confident Smile
If your Medicaid application for braces was denied, you’re not alone—and it doesn’t mean treatment is out of reach. Many families in New York explore flexible, affordable orthodontic care after Medicaid denial, and a personalized evaluation can help you understand your child’s options clearly.
Braces World Orthodontics offers free consultations and flexible payment plans for families in East Elmhurst, Ridgewood, and Freeport. If you’ve recently been denied coverage, our experienced team is here to help you explore every option available.
Request your free consultation today and take the next step toward a confident, healthy smile.