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13.3.2 Orthodontia Services
13.3.2.1 Benefits and Limitations
Orthodontia services are benefits of the CSHCN Services Program for clients with the following diagnosis codes:
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Diagnosis Code
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Description
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52400
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Major anomalies of jaw size, unspecified anomaly
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52401
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Major anomalies of jaw size, maxillary hyperplasia
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52402
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Major anomalies of jaw size, mandibular hyperplasia
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52403
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Major anomalies of jaw size, maxillary hypoplasia
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52404
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Major anomalies of jaw size, mandibular hypoplasia
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52405
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Major anomalies of jaw size, macrogenia
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52406
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Major anomalies of jaw size, microgenia
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52407
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Excessive tuberosity of jaw
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52409
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Major anomalies of jaw size, other specified anomaly
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52410
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Anomalies of relationship of jaw to cranial base, unspecified anomaly
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52411
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Anomalies of relationship of jaw to cranial base, maxillary asymmetry
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52412
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Anomalies of relationship of jaw to cranial base, other jaw asymmetry
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52419
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Anomalies of relationship of jaw to cranial base, other specified anomaly
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52451
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Abnormal jaw closure
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52452
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Limited mandibular range of motion
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52453
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Deviation in opening and closing of the mandible
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52454
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Insufficient anterior guidance
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52455
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Centric occlusion maximum intercuspation discrepancy
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52456
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Nonworking side interference
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52457
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Lack of posterior occlusal support
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52459
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Other dentofacial functional abnormalities
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74900
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Cleft palate, unspecified
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74901
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Cleft palate, unilateral, complete
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74902
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Cleft palate, unilateral, incomplete
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74903
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Cleft palate, bilateral, complete
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74904
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Cleft palate, bilateral, incomplete
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74910
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Cleft lip, unspecified
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74911
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Cleft lip, unilateral, complete
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74912
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Cleft lip, unilateral, incomplete
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74913
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Cleft lip, bilateral, complete
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74914
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Cleft lip, bilateral, incomplete
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74920
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Cleft palate with cleft lip, unspecified
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74921
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Cleft palate with cleft lip, unilateral, complete
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74922
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Cleft palate with cleft lip, unilateral, incomplete
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74923
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Cleft palate with cleft lip, bilateral, complete
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74924
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Cleft palate with cleft lip, bilateral, incomplete
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74925
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Other combinations of cleft palate with cleft lip
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7540
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Congenital musculoskeletal deformities of skull, face, and jaw
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75555
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Acrocephalosyndactyly
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7560
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Congenital anomalies of skull and face bones
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Prior Authorization Requirements
Prior authorization is required for all orthodontic services except for the initial orthodontic visit. Prior authorization is only approved for a complete orthodontic treatment plan. Prior authorization is not transferable to another dentist. The new provider must request prior authorization to complete the orthodontic treatment initiated by the previous provider.
Required Documentation
In addition to the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form, documentation must accompany the request for prior authorization and must include the date of service the documentation was obtained and a complete orthodontia treatment plan including all procedures required to complete full treatment, such as extractions, orthognathic surgery, upper and lower appliances, monthly adjustments, appliance removal if needed, and special appliances.
The CSHCN Services Program may also request the following:
• Properly occluded and anatomically trimmed dental models that demonstrate centric relation when standing on their bases for clients without cleft palate.
•A cephalometric radiograph with tracing.
•Facial photographs.
•A full series of radiographs or a panoramic radiograph.
The following information must be provided in the case of a transfer of care from one provider to another:
•A complete orthodontia treatment plan including all procedures required to complete full treatment such as, extractions, orthognathic surgery, upper and lower appliances, monthly adjustments appliance removal if needed, and special appliances.
•Explanation of why the client left the previous provider.
•Explanation of the treatment status.
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