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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 149 Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/05, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 o Frontal view, relaxed, teeth in occlusion; o Profile, right or left; o Intraoral, right or left sides, teeth in occlusion; o Intraoral, frontal, teeth in occlusion; and o Occlusal view (if photos are submitted without complete records); • Measurement of overbite and overjet; • Panoramic or full mouth intraoral radiographs; • Lateral cephalometric radiograph; and • Trimmed models; articulated or “rough-trimmed” models should indicate the proper occlusion, either with lines or a wax bite. Models that are unable to be articulated or are too damaged in shipping will not be evaluated.

Oral Surgery Guidelines Uncomplicated extractions, removal of soft tissue impactions or minor surgical procedures are considered basic services and are the responsibility of the general dentist. The member may be referred to a contracted plan oral surgeon when it is beyond the scope of the general dentist.

All referrals to an oral surgeon must be pre-approved by the plan prior to services being rendered.

To approve a pre-authorization for a member to a contracted plan oral surgeon the member must have the following conditions: • Third molar impactions • Severely dilacerated roots • A tooth broken below the bone level • Roots or roots apex in the sinus • Pain and/or swelling around the affected area

For approval for an oral surgeon pre-authorization for third molar extractions the following criteria must be met: • Internal or external resorption • Dentigerous cyst • Periodontal disease in connection with an adjacent third molar • Pathology involving the third molar • Recurrent pericoronitis • Non-restorable carious lesion