Submitting PA Requests for Comprehensive Orthodontic Treatment Requiring Orthognathic Surgery

[Reprinted from August 2015 Medicaid Bulletin]

The following records are required when submitting prior approval requests for combined comprehensive orthodontic treatment of the adolescent dentition (D8080) and orthognathic surgery to correct a skeletal imbalance:

1. Diagnostic Models

   a. Trimmed to centric occlusion

   b. Bite registration required

   c. Description of centric relation-centric occlusion shifts greater than 2mm

2. Three Extraoral Photographs

   a. Full face with patient at rest

   b. Right profile with patient at rest

   c. Full face with patient smiling as fully as possible

3. Five Intraoral Photographs

   a. Maxillary occlusal view

   b. Mandibular occlusal view

   c. Right lateral view in centric occlusion

   d. Left lateral view in centric occlusion

   e. Frontal view in centric occlusion

4. Radiographic Images

   a. Panoramic (labeled right and left)

   b. Lateral cephalometric with tracing and analysis (right lateral with teeth in occlusion and the patient in a relaxed lip posture)

   c. Posterioroanterior cephalometric if asymmetry present d. Individual periapical films as needed for special diagnostic concerns

5. Treatment Plan

   a. Necessary extractions

   b. Pre-surgical orthodontic treatment goals with specific measurements in all three dimensions

   c. Pre-treatment lateral cephalometric predictions showing anticipated orthodontic and surgical movements and resulting soft tissue profile

   d. Estimated time to complete pre-surgical orthodontics

   e. Post-surgical orthodontic treatment goals and estimated time to complete treatment

   f. Retention plan

6. Consultation notes from the provider who will be rendering the orthognathic surgery services indicating agreement with the proposed treatment plan

The following orthodontic records are allowed for the initial consultation visit for combined comprehensive orthodontic treatment and orthognathic surgery:

Procedure Code	Description
D0160	Detailed and Extensive Oral Evaluation
D0330	Panoramic film
D0340	Cephalometric film
D0470	Diagnostic casts
D0290	Posterior-anterior radiographic image (if needed)

 

When the patient is ready for surgery, additional records are needed as the interim records. These records must be submitted with the prior approval request for the orthognathic surgery. The Division of Medical Assistance (DMA) will grant an override of the lifetime limit to allow payment for the additional records required for the surgery request.

Note: The same records are required for orthognathic surgery requests submitted on behalf of beneficiaries who initiated their orthodontic treatment through a private-pay arrangement.