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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;
(3) comprehensive orthodontic procedures for treatment of cleft palate for treatment in conjunction with orthognathic surgery for a class III skeletal malocclusion, for treatment based on medical necessity due to functional impairment, or based on a score of 28 or greater on the Handicapping Labiolingual Deviation (HLD) Index Report, adopted by reference in 7 AAC 160.900, and completed by an orthodontist; the department will pay for interceptive orthodontic treatment for recipients under 13 years of age; when requesting approval for orthodontic treatment the provider must consider the recipient's willingness and ability to attend scheduled appointments and ability to maintain an acceptable level of oral hygiene, which is vital to the success of orthodontic treatment; the prior authorization request must be submitted by the orthodontist and must include
(A) a description of the condition including medical information to determine functional impairment;
(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) study models, if requested in the process of reviewing the prior authorization; 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; (b) If comprehensive orthodontic treatment commences earlier than 18 months after the most recent limited or interceptive orthodontic treatment, reimbursement for the comprehensive