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DISPARITIES BETWEEN QUALIFICATION AND FUNDING OF MEDICAID-COVERED ORTHODONTIC TREATMENT
Farah, Rayane
Farah, Rayane
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Thesis/Dissertation
Date
2025-08
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Oral Biology
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https://doi.org/10.34944/my4g-2z24
Abstract
Objectives: Medicaid coverage of orthodontic treatment in Pennsylvania, is granted for patients with a Salzmann Index (SI) score >25 and/or those with one of the automatic qualifiers (AQ) listed by the insurance company. Inconsistencies often exist between the clinical assessment of the patient’s qualification and the insurance’s funding decision. This study aimed to evaluate the predictability of the insurance’s funding decision using SI scores and AQs, compare clinical and insurance-based SI scores and investigate the contribution of different groups of AQs to funding approval.
Methods: 298 patients were included in this study. SI scores, presence and type of AQs, and the insurance’s funding decision were collected retrospectively. The level of agreement between the SI score, AQs and the insurance funding decision was compared. AQs were further grouped into 6 categories (Transverse, Vertical, Sagittal, Impaction, Multiple, Other) and the approval rates of each group were compared.
Results: The overall insurance approval rate for the 12-month study period was 46.3%. A discrepancy between the SI and AQs existed in 34.3% of the cases. In these cases, the AQs were more likely to correctly predict the insurance’s decision than the SI (63.1% vs 36.9% agreement). The insurance provider scored the SI on average, 1.79 points lower than clinicians (p= 0.002). Among the different categories of AQs, impaction was the most consistently approved (90.9%) followed by vertical at 82.9% while patients with AQs under “sagittal” were amongst the least likely to get approved at 57.9%.
Conclusions: There is a moderate level of agreement between clinical assessment of qualification and insurance approval. The study demonstrated that AQs are a stronger predictor of insurance approval compared to SI. Discrepancies between clinical and insurance-assigned SI scores suggest inconsistencies in evaluations and the need for standardization. Better assessment of AQ categories may enhance consistency in predicting insurance funding decisions.
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