Class V - Orthodontic Services. A. Benefits for orthodontic services will only be available until the end of the calendar year in which the Member turns age 19 if the Member:
1. Has fully erupted permanent teeth with at least 1/2 to 3/4 of the clinical crown being exposed (unless the tooth is impacted or congenitally missing); and
2. Has a severe, dysfunctional, handicapping malocclusion and is determined to be Medically Necessary.
B. All comprehensive orthodontic services require a pre-treatment estimate (PTE) by CareFirst, as described in the Estimate of Eligible Benefits section. The following documentation must be submitted with the request for a PTE:
1. ADA 2006 or newer claim form with service code requested;
2. A complete series of intra-oral photographs;
3. Diagnostic study models (trimmed) with wax bites or OrthoCad electronic equivalent, and
4. Treatment plan including anticipated duration of active treatment.
C. Covered benefits if a PTE is approved
Class V - Orthodontic Services. A. Benefits for orthodontic services will only be available if the Member:
1. Has fully erupted permanent teeth with at least 1/2 to 3/4 of the clinical crown being exposed (unless the tooth is impacted or congenitally missing); and
2. Has a severe, dysfunctional, handicapping malocclusion that meets a minimum score of 15 on the Handicapping Labio-Lingual Deviations Index (HLD) approved for use by the State of Maryland. Points are not awarded for aesthetics, therefore additional points for handicapping aesthetics will not be considered as part of the determination.
B. All orthodontic services require a pre-treatment estimate (PTE) to be submitted to the Dental Plan as described in Section 15.6F, Estimate of Eligible Benefits. The following documentation must be submitted with the PTE:
1. ADA 2006 or newer claim form with service code requested;
2. Diagnostic study models (trimmed) with wax bites or OrthoCAD™ electronic equivalent,
3. Cephalometric head film with measurements and analysis;
4. Panoramic or full series periapical radiographs;
5. Clinical summary with diagnosis;
6. HLD score sheet completed and signed by the orthodontist; and
7. Treatment plan including anticipated duration of active treatment.
Class V - Orthodontic Services. A. Benefits for orthodontic services will only be available if the Member:
1. Has fully erupted permanent teeth with at least 1/2 to 3/4 of the clinical crown being exposed (unless the tooth is impacted or congenitally missing); and
2. Has a severe, dysfunctional, handicapping malocclusion that meets a minimum score of 15 on the Handicapping Labio-Lingual Deviations Index (HLD) approved for use by the State of Maryland. Points are not awarded for aesthetics, therefore additional points for handicapping aesthetics will not be considered as part of the determination.
B. A pre-treatment estimate (PTE) for orthodontic procedures is required for members covered under Affordable Care Act policies, as described in Section 15.3F, Estimate of Eligible Benefits. Required documentation to accompany the PTE includes:
1. A completed current ADA claim form with service code requested and treatment plan including anticipated duration of treatment;
2. Digital scans or photographs of the original diagnostic study models in centric relations (left and right profile views, frontal view, occlusal view of individual arches);
3. Diagnostic quality extraoral photographs with profile, occlusal and frontal views in and out of occlusion;
4. Diagnostic quality panoramic and cephalometric radiographs;
5. Clinical summary with diagnosis; and
6. The completed original state-mandated assessment form (Handicapping Labio- Lingual Deviations, or HLD).
C. Covered benefits if the PTE is approved by the Dental Plan:
