55 Pa. Code § 1149.55 - Payment conditions for orthodontic services
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:
(i) Dentofacial abnormalities that severely
compromise the client's physical health, as manifested by markedly protruding
upper jaw and teeth, protruding lower jaw and teeth, the protrusion of upper
and lower teeth so that the lips cannot be brought together, under-developed
lower jaw and receding chin or marked asymmetry of the lower face.
(ii) Obvious difficulty in eating because of
the malocclusion, so as to require liquid or semisoft diet, or cause pain in
jaw joints during eating, or extreme grimacing or excessive motions of the
orofacial muscles during eating because of necessary compensation for anatomic
deviations.
(iii) Obvious severe
breathing difficulties related to the malocclusion, such as unusually long
lower face with downward rotation of the mandible and with lips that cannot be
brought together, chronic mouth breathing and postural abnormalities relating
to breathing difficulties-for example, head forward and extended, round
shouldered.
(iv) Lisping or other
speech articulation errors that are directly related to orofacial
abnormalities.
(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.
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