§ 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.
Source The provisions of this § 1149.55 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995. Immediately preceding text appears at serial pages (130979) to (130980).
Cross References This section cited in 55 Pa. Code § 1149.54 (relating to payment policies for orthodontic services).
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