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Attention Orthodontic providers:
Effective on or after January 1, 2025, prior authorization (PA) requests for orthodontic treatment indicating a medical condition as the primary reason for treatment must also include the following documentation to be considered for medical necessity:
- Current (within the past 12 months) specific recommendations for orthodontics, that include the condition needing to be addressed (e.g., sleep apnea, speech issues, etc.), from the treating medical specialist who has the subject matter expertise appropriate and necessary for management of the specific condition indicated;
AND
- All medical diagnostic documentation within the past 12 months, including tried and failed therapies utilized to address the condition.
HCA will not approve orthodontic treatment for a described medical condition without a specific recommendation for orthodontic treatment from the medical specialist treating the condition.
HCA is publishing a revised Orthodontic Services Billing Guide dated January 1, 2025, to reflect this guidance.
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