Download 2017 Connecticut Saltzmann Handicapping Malocclusion

Orthodontic Case Submissions
Please submit your orthodontic cases for review to:
Delta Dental of New Jersey, Inc.
P.O. Box 222
Parsippany, NJ 07054
Your orthodontic case submissions must include the following:
1. A completed standard ADA claim form
2. Narrative including:
a.
Treatment plan
b.
Treatment time
c.
Total case fee
d.
Initial case fee
e.
Retention fee
3. Diagnostic photographs are required, including three facial photographs (profile, frontal, and
smiling), and five intraoral photographs (frontal, right lateral, left lateral, and maxillary and
mandibular occlusal).
4. A properly completed and scored Salzmann Malocclusion Severity Assessment form
5. A panoramic and/or cephalometric radiograph
6. Additional documentation from referring general dentists, pediatric behavioral health or mental
health providers, or a statement that no other documentation was presented
7. A narrative description of any severe deviation(s) affecting the mouth and/or underlying
structures that would not be evident from the diagnostic materials provided
8. In lieu of photographs, properly trimmed study models, bite registration (will not be
returned)
Cases submitted for review without the documentation listed above will be returned to the submitting
office.
DDNJ/CT-2014
PS 11/13
1
Malocclusion Severity Assessment Scoring Guidelines
The following references correspond to the sample Salzmann Scoring Sheet which follows this section.
SECTION A. Intra Arch Deviation
•
Only the four maxillary incisors should be included in this category. Additionally, the maximum
score for this line cannot exceed eight (8) points, and no tooth may be scored twice, such as
counting a tooth as both crowded and rotated.
•
Only the four mandibular incisors should be included in this category. Additionally the maximum
score for this line cannot exceed four (4) points, and no tooth may be scored twice, such as
counting a tooth as both crowded and rotated.
•
Rotation in the posterior area only refers to tooth irregularities that interrupt the continuity of the
dental arch and involve all or part of the lingual or buccal surfaces such that rotated posterior
teeth have buccal or lingual surface(s) wholly or partially facing the proximal surface of adjacent
teeth.
SECTION B. Inter Arch Deviation
•
Overjet only refers to those maxillary incisors that have a labio axial inclination with mandibular
incisors occluding the palatal gingivae.
•
Overbite only refers to those maxillary incisors that occlude on or opposite the mandibular labial
gingivae or those mandibular incisors that occlude on the palatal gingivae.
SECTION 2. Posterior Segments
•
Mesio-distal deviation only refers to the mandibular teeth that have their buccal cusps (mesio
buccal cusp of the first permanent molar) occluding entirely mesial or distal to the accepted
normal relation to the maxillary teeth.
•
Posterior crossbite only refers to the maxillary posterior teeth that are buccally or lingually
displaced out of the entire occlusal contact with the opposing arch.
Closed Spacing means space insufficient for the complete eruption of a tooth. Only permanent teeth
may be counted when completing the malocclusion assessment record for the determination of medical
necessity. By definition, interceptive therapy is not a covered service unless it is needed to prevent a
skeletal abnormal developmental condition.
DDNJ/CT-2014
PS 11/13
2
D.O.B.: ___________________
ID#: _____________________
Member Name: _________________
DELTA DENTALOFNEWJERSEY
SALTZMANN HANDICAPPING MALOCCLUSION ASSESSMENT RECORD
(Please mark the affected tooth numbers.)
A. INTRA-ARCH DEVIATION
SCORE TEETH
AFFECTED ONLY
MAXILLA
MANDIBLE
MISSING
CROWDED
Ant
7 8 9 10
Post
3 4 5 6
14 13 12 11
7 8 9 10
Ant
23 24 25 26
Post
19 20 21 22
7 8 9 10
3 4 5 6
14 13 12 11
3 4 5 6
14 13 12 11
23 24 25 26
30 29 28 27
SPACING
ROTATED
3
OPEN
CLOSED
7^8^9^10
7 8 9 10
4
5
6
14 13 12 11
23 24 25 26
NO.
23^24^ 25^26
3
4
5
SCORE
X2
6
XI
14 13 12 11
23 24 25 26
19 20 21 22
19 20 21 22
19 20 21 22
19 20 21 22
30 29 28 27
30 29 28 27
30 29 28 27
30 29 28 27
Ant = anterior teeth (4 incisors). Post = posterior teeth (including canine, premolars, and first molar). No. = number of teeth affected.
B. INTER-ARCH OEVIATION
POINT
VALUE
XI
XI
TOTAL SCORE
1. Anterior Segment
OVERJET
SCORE MAXILLARY TEETH
AFFECTED ONLY EXCEPT
OVERBITE*
OVERBITE(MAX4TEETH)
7
24
7 8 9 10
8
25
9 10
26
23
CROSSBITE
OPENBITE
7 8 9 10
7 8 9 10
'Score maxillary or mandibular Incisors. No. = number of teeth affected.
NO.
POINT
VALUE
SCORE
X2
TOTAL SCORE
2. Posterior Segments
SCORE AFFECTED MAXILLARY
TEETH ONLY
RELATE MANDIBULAR TO
MAXILLARY TEETH
SCORE TEETH
AFFECTED ONLY
DISTAL
RIGHT
MESIAL
LEFT
RIGHT
CROSSBITE
LEFT
RIGHT
LEFT
NO.
POINT
VALUE
OPENBITE
RIGHT
LEFT
XI
Canine
Premolar
XI
2ND Premolar
XI
ST
1
ST
1
XI
Molar
TOTAL SCORE
GRAND TOTAL
G. OTHER DEVIATIONS (use additional sheet if necessary)
If the total score is less than twenty-four (26) points Delta Dental shall consider additional information of a substantial nature about the
presence of other severe deviations affecting the mouth and underlying structures. Other deviations shall be considered severe if, left
untreated; they would cause irreversible damage to the teeth and underlying structures.
Is there presence of other severe deviations affecting the mouth and underlying structures? (If any, comment below). Y/N
Records Submitted:  FMS  Panorex  Models  Photographs  Other: ________________________________________
Date of Records: ___________________________________
Comments: _________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
ASSESSMENT RECORD Prepared by:
Signature
DDNJ/CT-2014
PS 11/13
Date
3
Please submit your completed Assessment
Diagnostic materials and Claim form to:
Delta Dental of New Jersey, Inc.
P.O. Box 222
Parsippany, NJ 07054
SCORE