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MEDICAL ASSISTANCE BULLETIN
COMMONWEALTH OF PENNSYLVANIA z DEPARTMENT OF PUBLIC WELFARE
ISSUE DATE
October 21,1996
EFFECTIVE DATE
NUMBER
03-96-06
October 28,1996
SUBJECT
BY
Information on New Procedures for Submitting
Evaluating Orthodontic Prior Authorization Requests
Darlene C.Collins, M.Ed., M.P.H.
Deputy Secretary for Medical Assistance Programs
PURPOSE:
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
-2The 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, 1996.
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.
___YES ___NO
- Maxillary incisors opposite to gingival mucosa of lower.
___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
IMPORTANT
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:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_____________________________________________________
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
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. 4
2. 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