Szemerakis v. Comm, Social Services

Connecticut Supreme Court

274 Conn. 1 (2005)

June 7, 2005


In a narrow but disappointing decision, the Connecticut Supreme Court upheld that state’s draconian utilization control procedures governing orthodontic treatment for children insured under the state’s Medicaid plan.

Under Conn. Agencies Regs. § 17-134d-35(e), the Department of Social Services used a point system assessment test as part of its method for determining whether orthodontic treatment was medically necessary for Medicaid recipients in the Early Periodic Screening Diagnosis and Treatment (“EPSDT”) program. An orthodontist determined that the child’s condition warranted eight points on the assessment test; 24 were required for eligibility under the first prong of § 17-134d-35(e). The trial court held that the Department had improperly established eligibility requirements that were stricter than those authorized by the Medicaid Act. The supreme court disagreed. 42 U.S.C.S. § 1396d(r)(3), which controlled over the more general provision, § 1396d(r)(5), required states to provide dental care that included relief of pain and infections, restoration of teeth, and maintenance of dental health. Conn. Agencies Regs. § 17-134d-35(e) was valid as a reasonable utilization control that did not cause recipients to receive less care than was envisioned by 42 U.S.C.S. § 1396d(r)(3). It was a reasonable attempt to objectively balance orthodontics used for primarily aesthetic reasons and as a medically necessary method of treating significant malocclusions.

In doing so, the court passed on a golden opportunity to opine that the broad EPSDT mandate (providing for coverage of “medically necessary” services) of § 1396d(r)(5) would provide the impetus to attack the “neglected epidemic” of untreated oral health problems for the mental and physical health of children. Instead, the “importance of adequate oral healthcare to all members of our society” notwithstanding, the court indicated that the crisis presents a “complicated problem, the resolution of which lies beyond [our] province.” Fn 14 at 37. As a result, the court reversed the trial court’s decision, and remanded the case to the trial court for reversal and dismissal.

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