Current through Register No. 40, October 3, 2024
(a) Comprehensive orthodontic treatment shall
be covered for recipients under 21 years of age who demonstrate severe
handicapping malocclusion, which limits function and if left untreated would
result in damage to the dental structures or surrounding tissue, due to one or
more of the following conditions:
(1)
Crowding of teeth greater than 12 mm in a single arch;
(2) Deep impinging overbite with destruction
of tissue;
(3) Crossbite of
anterior teeth with destruction of tissue;
(4) Overjet greater than 9 mm;
(5) Reverse overjet greater than 3.5 mm;
or
(6) Severe traumatic deviations
demonstrated by gross pathology.
(b) Interceptive orthodontic treatment shall
be covered for recipients under 21 years of age who have at least one of the
following conditions:
(1) Constricted
palate;
(2) Deep impinging overbite
with demonstration of destruction of tissue;
(3) Anterior crossbite; or
(4) Dentition exhibiting results of harmful
habits.
(c) Limited
orthodontic treatment shall be covered for recipients under 21 years of age, by
report, and no more than once per arch per recipient per lifetime.
(d) Comprehensive and interceptive
orthodontic treatment shall:
(1) Each be
covered once per recipient per lifetime; and
(2) Require prior authorization in accordance
with
He-W
566.07.
(e) Sealants shall be present on all
permanent molars prior to the provider requesting prior authorization in (d)(2)
above.
(f) Any dental provider who
undertakes orthodontic treatment for children with severe handicapping
malocclusions shall be qualified by training and experience in accordance with
Den
302.04.
(g) In addition to the information required
at
He-W 566.07,
prior authorization requests for comprehensive and interceptive orthodontic
treatment shall include the following:
(1) A
treatment plan, which shall address and include the following:
a. Diagnosis and explanation describing the
nature of the severe handicapping malocclusion or functional limitation
associated with the malocclusion with sufficient detail and documentation to
support and demonstrate the existence of conditions described in (a)-(b) above
or
He-W
546.05;
b.
Justification for early treatment if the request is for comprehensive treatment
and deciduous teeth are present or not all of the permanent teeth have
erupted;
c. Name of the referring
dentist;
d. Description of the
chief complaint expressed by the referring dentist or the recipient or legal
representative;
e. Specific
treatment objectives;
f.
Description of the plan for comprehensive oral care during orthodontic
treatment;
g. Signed statement from
the provider attesting that:
1. The recipient
has received an oral examination and was found to be free of untreated oral
disease;
2. The recipient
demonstrates oral hygiene habits consistent with being able to prevent
inflammation and dental decay during orthodontic treatment; and
3. Sealants are in place on all of the
recipient's unrestored erupted molars; and
h. Signed statement from the recipient or
legal representative acknowledging the recipient's understanding and
acceptance:
1. Of the provider's treatment
plan including, but not limited to, the recipient's willingness to adhere to an
oral hygiene regimen necessary to prevent inflammation and decay, to attend any
scheduled appointments, and to properly wear and maintain the appliance;
2. Of the provider's right to
discontinue treatment for non-compliance, including, but not limited to, the
recipient's failure to adhere to oral hygiene expectations, missed
appointments, and failure to properly wear or maintain appliances;
3. That the Title XIX program will not pay
for the cost of orthodontic treatment beyond the recipient's 21st birthday;
and
4. That the Title XIX program
will not pay for the cost of orthodontic treatment more than once per recipient
per lifetime if treatment is terminated due to non-compliance with the
treatment plan as documented by the provider;
(2) Diagnostic model taken within 30 days of
submitting the prior authorization request;
(3) Treatment cost estimate;
(4) Except as allowed by (h) below,
radiographs that are current and of adequate quality to allow for an accurate
diagnosis of the malocclusion; and
(5) Assurance that the requested treatment is
the least restrictive, most cost-effective treatment for the
malocclusion.
(h) When
requesting interceptive treatment, photographs may be submitted in lieu of
radiographs, provided the photographs clearly demonstrate the criteria being
considered for approval.
(i)
Banding shall occur within 60 days of the receipt of the prior authorization
approval.
(j) Comprehensive
orthodontic treatment shall be covered only if the recipient adheres to the
treatment plan of care specified at (g)(1) above.
(k) Treatment may be terminated by the
provider for non-compliance, including, but not limited to, the recipient's
failure to adhere to oral hygiene expectations, missed appointments, and
failure to properly wear or maintain appliances.
(l) Providers shall supply the department
with treatment progress reports at the following intervals:
(1) A progress report immediately following
the 12th month of treatment, including a description of recipient compliance
with the provider's treatment plan and a report of objectives achieved to
date;
(2) A final treatment report,
including diagnostic models or post treatment photographs of the dentition in
centric relation from center, right and left sides, submitted at the conclusion
of treatment which demonstrate that the treatment goals have been met; and
(3) Immediate report of any
patterns of non-compliance, if applicable.
(See Revision Note at chapter heading He-W 500); ss by
#5639, eff 6-17-93; ss by #7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by
#9902, eff 6-1-11
