Page 94

Effective Date:

Approval Date: 94

Section 4 - Orthodontic Coverage Orthodontic procedures require prior approval. Orthodontia procedures will be approved for handicapping malocclusions only. A “handicapping” malocclusion is a condition that constitutes a hazard to the maintenance of oral health and interferes with the well-being of the recipient by causing: • Impaired mastication, • Dysfunction of the temporo-mandibular articulation, • Susceptibility to periodontal disease, • Susceptibility to dental caries, and • Impaired speech due to malpositions of the teeth. Assessment of the most handicapping malocclusion is determined by the magnitude of the following variables: degree of malalignment, missing teeth, angle classification, overjet and overbite, open bite, and crossbite. A Salzman Index score of 26 or greater will be used as criteria for “medically necessary” benefits. Approval for treatment will be assessed in a manner consistent with “Handicapping Malocclusion Assessment to Establish Treatment Priority,” by J. A. Salzmann, DDS, American Journal of Orthodontics, October 1968. A request for prior approval shall be accompanied by documentation as directed by the dental plan to substantiate medically necessary orthodontic benefits. Post treatment records may be furnished upon request. Approval may be made a complete comprehensive case of active orthodontic treatment. Additional consideration for extenuated cases may be approved by the dental plan‟s orthodontic consultant if found to be medically necessary.

Minor Treatment To Control Harmful Habits D8210 Removable appliance therapy. Requires prior authorization. D8220 Fixed appliance therapy. Requires prior authorization.

Comprehensive Orthodontic Treatment Of Permanent Dentition/Transitional Dentition These procedures require prior authorization. Orthodontia procedures will be approved for documentation as directed by the dental plan to substantiate medically necessary orthodontic benefits.

Code Procedure Comment D0140 Limited Oral Evaluation D8070* Comprehensive treatment of transitional dentition D8080* Construct and place maxillary or mandibular appliance with retainer & active treatment D8210 Removable Appliance Therapy D8220 Fixed Appliance Therapy D8660 Pre-ortho visit/records D8680 Orthodontic retention D8690 Active treatment transfers . Use when recipient transfers from one provider to another. D8999 Unspecified orthodontic procedure