MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE

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1 MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE ISSUE DATE EFFECTIVE DATE NUMBER October 21,1996 October 28, SUBJECT BY Information on New Procedures for Submitting Evaluating Orthodontic Prior Authorization Requests PURPOSE: Darlene C.Collins, M.Ed., M.P.H. Deputy Secretary for Medical Assistance Programs The purpose of this bulletin is to announce the replacement of the Salzmann Evaluation Index with the new Orthodontic Decision Checklist. SCOPE: This bulletin applies to all providers enrolled as board certified or board eligible orthodontists in the Medical Assistance Program. BACKGROUND: In the past, orthodontists used the Salzmann Evaluation Index (MA301-94) for evaluating cases to be sent to the Prior Authorization Unit for review. The recipient needed a score of 25 points or higher upon examination and evaluation by the orthodontist. The Salzmann Index is being replaced with the new Orthodontic Decision Checklist. DISCUSSION: The Department and the provider community have found ongoing problems with point scoring of orthodontic requests using the Salzmann Index. Although some components of the Salzmann Index are helpful in determining whether dental conditions are considered handicapping, the Department felt that a comprehensive list of handicapping factors would be more helpful to orthodontic providers. In consultation with the Pennsylvania Dental Association, the Department developed the new Orthodontic Decision Checklist, which includes some helpful components from the Salzmann Index. COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: Department of Public Welfare PO Box 8044 Harrisburg, Pennsylvania 17105

2 The Orthodontic Decision Checklist consists of eight areas for consideration in determining a handicapping malocclusion. If one or more of these areas in #2 through #8 is met, the orthodontist must submit the MA96, diagnostic study models and x-rays to the Prior Authorization unit who will determine if the request meets the requirements established by medical assistance regulations. Accompanying this bulletin is the Orthodontic Decision Checklist and instructions on how to complete the form. PROCEDURE: Effective October 28, 1996 providers must begin using the Orthodontic Decision Checklist. The Department will not accept the Salzmann Evaluation Index after December 16,

3 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE PRIOR AUTHORIZATION SECTION O R TH O D O N T I C D E C I S I O N C H E C K L I S T 1. PERMANENT TEETH FULLY ERUPTED YES NO 2. OVERBITE - Palatal Impingement of the lower incisors on the upper gingival mucosa. - Maxillary incisors opposite to gingival mucosa of lower. YES NO YES NO 3. OPEN-BITE - Anterior open-bite YES NO - Posterior open-bite YES NO 4. OVERJET - At least 9 mm overjet (measuring from facial surface of lower incisor to incisal of upper incisor). YES NO 5. CROSS-BITE - Anterior locked lingual tooth/teeth. YES NO - Two or more teeth in same arch in posterior segment. YES NO - Upper posterior tooth/teeth in buccal cross-bite to lower. YES NO 6. IMPACTIONS - Please explain position and degree 7. BLOCKED OUT CANINES YES NO 8. HYPERTROPHIC GINGIVAE - A direct result of excessive crowding. YES NO

4 I M P O R T A N T COSMETIC ORTHODONTICS IS NOT COMPENSABLE IN D.P.W. REGULATIONS. Please use the criteria on the opposite side at the initial examination of the patient to determine whether a handicapping malocclusion exists. If there is a handicapping malocclusion, models and x-rays can be taken and submitted to the Prior Authorization Unit. PLEASE COMPLETE THE FOLLOWING Description of patient s condition and diagnosis: Treatment Plan: Remarks:

5 INSTRUCTIONS FOR USING ORTHODONTIC DECISION CHECKLIST INTER-ARCH DEVIATION 1. Anterior Segment OVERBITE refers to the occlusion of the maxillary incisors on or opposite the labial gingival mucosa of the mandibular incisors, or the mandibular incisors occlude directly on the palatal mucosa back of the maxillary incisors. DO NOT CONSIDER OVERBITE unless the LOWER INCISORS IMPINGE ON THE PALATE or the UPPER INCISORS IMPINGE ON OR ARE OPPOSITE THE LOWER GINGIVA. FIG. 1 OPEN-BITE OF INCISORS refers to vertical interarch dental separation between the maxillary and mandibular incisors when the posterior teeth are in terminal occlusion. Open-bite is recorded in addition to overjet if the incisal edges of the labially protruding maxillary incisors are above the incisal edges of the mandibular incisors when the posterior teeth are in terminal occlusion. EDGE-TO-EDGE OCCLUSION IS NOT ASSESSED AS OPEN-BITE FIG. 2 DO NOT CONSIDER OVERJET if distance is less than NINE (9) MILLIMETERS. FIG. 3

6 CROSS-BITE OF INCISORS refers to the maxillary incisors that are in lingual relation to their opposing teeth in the mandible when the maxillary and mandibular dental arches are in terminal occlusion. FIG Posterior Segment CROSS-BITE OF POSTERIOR TEETH refers to teeth in the buccal segment that are positioned lingually or buccally out of ENTIRE OCCLUSAL CONTACT with the teeth in the opposing jaw when the rest of the teeth in the dental arches are in terminal occlusion. EDGE TO EDGE OCCLUSION IS NOT ASSESSED AS CROSS-BITE. FIG. 5 OPEN-BITE OF POSTERIOR TEETH refers to the vertical interdental separation between upper and lower canines, bicuspids, and first molars when the rest of the teeth in the dental arches are in terminal occlusion. CUSP TO CUSP OCCLUSION IS NOT ASSESSED AS AN OPEN-BITE. FIG. 6

Attachment G. Orthodontic Criteria Index Form Comprehensive D8080. ABBREVIATIONS CRITERIA for Permanent Dentition YES NO

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