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5/11/2012, Register 202; am 5/1/2016, Register 218; am 12/1/2022, Register 244) Statutory Authority: Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.153. Orthodontic services. (a) The department will pay a provider for only those orthodontic dental services identified in the Fee Schedule: Dental Services for Children, adopted by reference in 7 AAC 160.900, and that have prior authorization form the department. The department will pay for orthodontic services rendered by an orthodontist who is enrolled in accordance with 7 AAC 110.140, as follows:
(1) limited orthodontic treatment of the primary dentition for a malocclusion that does not involve the entire dentition; the department will pay for limited orthodontic treatment for recipients under 21 years of age; treatment may be directed at the existing problem or at one or more aspects of a larger problem when the decision is made to defer or forego more comprehensive therapy; the prior authorization request must be submitted by the orthodontist and must include
(A) a description of the condition;
(B) a description of the orthodontic appliance;
(C) a scored Handicapping Labiolingual Deviation (HLD) Index Report, adopted by reference in 7 AAC 160.900, completed and signed by the orthodontist;
(D) a treatment plan for correcting the condition;
(E) panoramic radiographs;
(F) other medical or dental information to support the requested orthodontic treatment, including required extractions or orthognathic surgery; and
(G) an Orthodontic Referral Oral Health and Hygiene Assessment, adopted by reference in 7 AAC 160.900, completed and signed by the referring dentist;
(2) interceptive orthodontic treatment of the primary or transitional dentition to redirect ectopically erupting teeth, correct isolated dental crossbite, or recover minor space loss where overall space for erupting teeth is adequate; the department will pay for interceptive orthodontic treatment for recipients under 13 years of age; the prior authorization request must be submitted