1. That sufficient functional disability be present as a result of disease, trauma, congenital anomalies or developmental dysfunction. This functional disability must be directly related to a dent maxillofacial (maxilla and mandible) abnormality and must include one or more of the following:
a. Significant intraoral trauma while chewing related to malocclusion. Information should be supplied which indicates the severity and duration of the trauma and the extent of the interruption to daily activities. This may include recurrent damage to the soft tissues of the mouth during mastication, lower incisors injuring the soft tissue of the palate, cheek biting, lip biting, impingement or irritation of buccal or lingual soft tissues of the opposing arch. The injury or damage to soft tissues must be documented by objective findings in the medical record and supported by photos.
b. Speech abnormalities that result in an unintelligible language, which have not responded to speech therapy or frenulectomy.
c. Documented loss of chewing or incisive function.
d. Congenital condition where there are dentomaxillofacial deformities.
2. Significant over or underjet, documented by one of the following:
a. A reverse overjet of 3mm or more, in cases of maxillary deficiency, or mandibular excess.
b. An overjet of 4mm or more, in cases of mandibular deficiency.
c. Open bite of 4mm or more.
d. Deep bite of 7mm or more.
e. Less than six (6) posterior teeth in functional opposition to other teeth as a result of abnormal growth or development (as opposed, to the result of tooth loss in the arch).
The following documents are required to consider the predeterminations of orthodontic services;
1. It must be accompanied with the completed form 193.
2. Lateral cephalometric radiography.
3. Tracing of the cephalometric with the corresponding measurements.
4. Photographs intra and extra oral pre-orthodontics.
5. Report that includes diagnosis (ICD-10) and corresponding CDT code.
6. Study model if necessary.
