Attention Orthodontic providers:
Retroactive to dates of service on and after July 1, 2024, prior authorization (PA) requests for orthodontic treatment, indicating palate soft tissue destruction due to a deep impinging overbite, requires photographic evidence with adequate resolution and exposure. The photographic evidence must clearly show the area of reported tissue destruction.
The Health Care Authority (HCA) requires the following supporting documentation:
- A high-magnification, high-resolution
- Open-mouth, anterior palate photo of adequate exposure, clearly showing lingual aspects of all maxillary anterior teeth and surrounding soft tissues including the incisive papilla
- Submental photo
- Both open-mouth and submental photos
Failure to submit the required documentation will result in the PA request being rejected.
The revised criteria can be found in the Orthodontic Services Billing Guide, published July 1, 2024.
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