Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1149 - DENTISTS' SERVICES
PAYMENT FOR DENTISTS' SERVICES
Section 1149.55 - Payment conditions for orthodontic services
Current through Register Vol. 54, No. 44, November 2, 2024
Payment for orthodontic services is subject to the following conditions and requirements:
(1) The Department has authorized for the services prior to provision of the services as referenced in § 1149.52(j)(3) (relating to payment conditions for various dental services).
(2) The orthodontist is Board eligible or Board certified as defined in § 1149.2 (relating to definitions).
(3) They are necessary to prevent irreversible damage to the teeth or their supporting structures.
(4) They are necessary to treat acute dental problems as evidenced by the following factors:
(5) The recipient has a fully erupted set of permanent teeth.
(6) The recipient is 20 years of age or younger except as noted in paragraph (7).
(7) The recipient is 21 years of age or older but was receiving orthodontic services through the MA Program when the recipient turned 21 years of age.
(8) The recipient scored 25 or higher on the Salzmann Evaluation Index upon examination and evaluation by the orthodontist.
This section cited in 55 Pa. Code § 1149.54 (relating to payment policies for orthodontic services).