TMPPM 2011 > Children's Services Handbook > Texas Health Steps (THSteps) Dental > Documentation Requirements > Orthodontic Services

4.3.2 Orthodontic Services

Requests for orthodontic services must be accompanied by all of the following documentation:

•An orthodontic treatment plan. The treatment plan must include all procedures required to complete full treatment (e.g., extractions, orthognathic surgery, upper and lower appliance, monthly adjustments, anticipated bracket replacements, appliance removal if indicated, special orthodontic appliances). The treatment plan should incorporate only the minimal number of appliances required to properly treat the case. Requests for multiple appliances to treat an individual arch are reviewed for duplication of purpose.

•Cephalometric radiograph with tracing models.

•Completed and scored HLD sheet with diagnosis of Angle class (26 points required for approval of non-cleft palate cases).

•Facial photographs.

•Full series of radiographs or a panoramic radiograph; diagnostic-quality films are required (copies are accepted and radiographs will not be returned to the provider).

•Any additional pertinent information as determined by the dentist or requested by TMHP's Dental Director. Requests for crossbite therapy require properly trimmed models to be retained in the office and must demonstrate the following criteria:

•Posterior teeth. Not end-to-end, but buccal cusp of upper teeth should be lingual to buccal cusp of lower teeth.

•Anterior teeth. The incisal edge of upper should be lingual to the incisal of the opposing arch.

The dentist should be certain that radiographs, photographs, and other information are properly packaged to avoid damage. TMHP is not responsible for lost or damaged materials.

Refer to: Form CH.15, "THSteps Dental Mandatory Prior Authorization Request Form" in this handbook.