Prior Authorization Request (Orthodontic Treatment)

Prior Authorization Request: Orthodontic Treatment

(Use explicit status markers such as "Not performed," "Pending," "Not available," or "Not required by payer" where information is missing. Do not infer diagnoses, index scores, or tissue trauma findings. Include only content supported by exam, imaging, or specialist documentation.)

Patient Name: [Patient name]

Date of Birth: [DOB]

Member ID: [Member ID]

Request Type: [Initial / Re-authorization / Completion]

Date of Submission: [Submission date]

Requested Start Date: [Requested start date]

Treating Orthodontist: [Orthodontist name], [Credentials], NPI: [NPI]

Practice/Service Location: [Practice name and address]

Payer/Plan: [Payer and plan name]

Program Type: [Medicaid FFS / Medicaid MCO / Commercial / EPSDT / Craniofacial Pathway / Other]

Date of Clinical Exam: [Exam date]

Date of Diagnostic Records: [Date(s) of records]

Executive Summary

(Provide 4–8 high-signal bullet points for rapid reviewer orientation. Select the most probative facts without duplicating content from other sections.)

• [Primary diagnosis with key quantitative finding]
• [Top 2–4 objective measurements or index results supporting severity]
• [Documented functional and/or health impacts]
• [Requested service level and appliance type]
• [Index used, version, total score/grade, and threshold status] (State "Meets payer threshold per [payer rule]" or "Index not required for this pathway.")
• [Summary of attached records]

Medical Necessity Narrative

[Summary statement establishing that orthodontic treatment is requested to treat a documented malocclusion or dentofacial condition with functional and/or health consequences, not primarily cosmetic, with explicit linkage from the specific malocclusion to its impacts]

• [Problem 1]: [Objective findings] → [Resulting functional/health impact] → [Why orthodontic intervention is required now and likely course without treatment] (Include brief patient quote only if it directly supports functional impairment and aligns with clinical findings.)
• [Problem 2]: [Objective findings] → [Impact] → [Why now / risk of worsening]
• (Add additional problems as needed. Prioritize clinician-observed findings for tissue trauma and occlusal dysfunction.)

Eligibility and Coverage Context

(Include only if payer rules depend on these factors. Omit section entirely if not applicable.)

• Age: [Age at request]; anticipated start: [Date]; anticipated completion: [Date range]
• Program pathway: [EPSDT / Craniofacial anomaly / Orthognathic surgery / Trauma / Cleft team / Standard medical necessity]
• Transfer/continuation status: [New start / Transfer / Continuation] (Include prior provider info if applicable.)
• Eligibility verification: [Verified / Not yet verified] (Flag if submission is deferred pending confirmation.)

History

Chief Concern: [Reason patient/guardian sought orthodontic evaluation]

Pertinent Dental History: [Prior orthodontic treatment with type, dates, outcomes, and reason for discontinuation if applicable; relevant extractions; space maintenance; orthopedic appliances]

Pertinent Medical History: [Conditions affecting orthodontic necessity or safety: craniofacial anomalies, syndromes, airway/speech diagnoses, trauma history] (Include only if supported by documentation.)

Functional Symptoms: [Chewing limitations, pain, speech concerns, soft tissue injury, sleep/airway symptoms] (Include only if supported by clinical exam or specialist documentation. Do not infer medical diagnoses.)

Clinical Examination Findings

Dentition Stage: [Primary / Mixed / Permanent]; [Eruption status of key teeth]; [Retained primary teeth]

Extraoral/Facial: [Facial symmetry]; [Profile classification]; [Lip competence at rest]; [Vertical proportions if relevant]

Intraoral/Oral Health Status: Caries: [Active / Controlled]; Oral hygiene: [Assessment]; Periodontal: [Concerns if any]; [Missing/supernumerary teeth]; [Developmental anomalies]

Occlusion:

• Angle classification: Molar R: [Class I / II / III], L: [Class I / II / III]; Canine R: [Class I / II / III], L: [Class I / II / III]
• Overjet: [Value] mm
• Overbite/Open bite: [Overbite in mm and % coverage / Anterior open bite in mm]
• Crossbites: [Anterior / Posterior / None]; [Unilateral / Bilateral]; Teeth: [Teeth involved]; Functional shift: [Present / Absent]
• Crowding/Spacing: Maxillary: [mm]; Mandibular: [mm]; [Arch length discrepancy if calculated]
• Midline deviation: [Maxillary to facial in mm]; [Mandibular to maxillary in mm]; [Direction]
• Impactions/Ectopic eruption: [Teeth involved with clinical and radiographic correlation]

(If any measurement required by payer criteria or index scoring was not obtained, state "Not measured" with reason and plan to obtain.)

Diagnostic Records Summary

(Checklist with dates and brief interpretive notes. Confirm diagnostic quality and demonstration of qualifying criteria.)

• Photographs: Date: [Date]; Views: [Intraoral and extraoral views obtained]; Quality: [Diagnostic / Non-diagnostic]; Demonstrates qualifying criteria: [Yes / No with specification]
• Models/Scans: Type: [Digital scan / Plaster / 3D printed photos]; Date: [Date]; Intercuspation confirmed: [Y / N]; Notes: [Interpretive findings]
• Panoramic radiograph: Date: [Date]; Key findings: [Missing teeth, impactions, eruption status, pathology]
• Lateral cephalometric: Date: [Date]; Tracing attached: [Y / N]; Skeletal classification: [Class I / II / III]; Key findings: [Relevant angular/linear findings]
• CBCT: [Not obtained / Date: [Date]]; Indication: [Clinical justification]; Findings: [Summary] (Include only if clinically justified.)

Index Scoring

(Include only when an index is used or required by payer. If not required, state "Index scoring not required by this payer for this request type" or omit section entirely.)

• Index: [Name and version]; Date scored: [Date]; Scored by: [Name/credentials]; Data source: [Clinical exam / Models / Photos]
• HLD (if used): Version: [State modification]; Total score: [Value]; Components: [Overjet, overbite/open bite, displacement, crossbite, other contributing factors]; Automatic qualifiers: [Cleft-related / Traumatic deviations / Tissue destruction / None]; Worksheet attached: [Y / N]; Threshold status: [Meets / Does not meet] per [payer rule]
• IOTN (if used): DHC grade: [1–5]; AC score: [1–10 / Not used]; Worst feature: [Description]; Threshold status: [Meets / Does not meet] per [payer rule]
• Other index: [Name/version]; Score: [Value]; Threshold status: [Meets / Does not meet] per [payer rule]

Assessment and Diagnoses

• Primary Diagnosis: [Malocclusion classification]; [Craniofacial anomaly if applicable]
• Secondary Diagnoses: [Supporting conditions: soft tissue trauma, impacted teeth, congenital absence, other] (Include only if supported by documentation.)
• Codes: CDT: [Requested orthodontic service codes]; ICD-10-CM: [Diagnosis codes if required for payer linkage]

Treatment Plan

• Requested Services: [Comprehensive / Limited / Interceptive / Phase I / Phase II / Retention]; [Fixed / Removable / Aligners]; Arches: [Upper / Lower / Both]
• Proposed Appliances and Sequence: [Expanders, functional appliances, fixed appliances, aligners, TADs, other with key phases and sequencing]
• Extractions/Surgical/Adjunctive: [Planned extractions]; [Expose-and-bond]; [Orthognathic surgery coordination]; [Frenectomy]; [Other / None]
• Estimated Duration: [Range in months]; Assumptions: [Compliance-dependent factors, growth considerations]
• Treatment Objectives Linked to Function/Health: [Objectives explicitly tied to documented functional risks, e.g., eliminating traumatic impingement, resolving functional shift, reducing periodontal risk]
• Alternatives Considered: [Alternatives and why insufficient for current functional/health needs]

(For re-authorization/continuation: Include progress summary, compliance considerations, revised timeline, and note updated diagnostic records attached.)

Interdisciplinary Documentation

(Include only when authorization rationale cites a medical condition or surgical pathway. If specialist documentation is pending, state "Specialist documentation requested; not yet received" and indicate whether submission is deferred.)

• Specialist: [Name, discipline]; Most recent evaluation: [Date]
• Recommendation for orthodontics: [Summary of recommendation related to condition]
• Relevant diagnostics: [Sleep study / Speech evaluation / Craniofacial team plan with key findings]
• Prior therapies: [List if relevant]
• Specialist letters attached: [Y / N]

Attachments Checklist

(Confirm inclusion, date, and labeling. Each attachment should include patient name, member ID, date created, and provider name per payer requirements.)

• Prior authorization request form / portal confirmation: [Included / Not included]; Date: [Date]
• Medical necessity narrative (this note): [Included]; Date: [Date]
• Intraoral photographs: Views: [List]; Date: [Date]; Labeled: [Y / N]
• Extraoral photographs: Views: [List]; Date: [Date]; Labeled: [Y / N]
• Panoramic radiograph: Date: [Date]; Labeled: [Y / N]
• Cephalometric radiograph: Date: [Date]; Labeled: [Y / N]
• Cephalometric tracing/analysis: [Included / Not included]
• Models or scans: Type: [Type]; Date: [Date]; Labeled: [Y / N]
• Index scoring worksheet(s): Type: [HLD / IOTN / Other / N/A]; Completed: [Y / N]
• Caries risk assessment / periodontal summary: [Included / Not required]
• Specialist letters and diagnostic reports: [Included / Not applicable]; Date(s): [Date(s)]
• Additional payer-required forms: [Included / Not required]; [Specify if applicable]

Attestation and Signature

The undersigned attests that the records submitted are accurate, correspond to the identified patient, and were used to establish medical necessity. Documentation is complete to the best of the provider's knowledge.

Signature: [Signature]

Printed Name: [Provider name]

Credentials: [Credentials]

Date: [Date signed]