COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE PRIOR AUTHORIZATION UNIT ORTHODONTIC DECISION CHECKLIST RECIPIENT NAME RECIPIENT I.D. NUMBER 1. PERMANENT TEETH FULLY ERUPTED YES NO 2. OVERBITE YES YES NO NO Palatal Impingement of lower incisors on the upper gingival mucosa. Maxillary incisors opposite to gingival mucosa of lower. 3. OPEN-BITE YES YES NO NO Anterior open-bite. Posterior open-bite. 4. OVERJET YES NO At least 9mm overjet (measuring from facial surface of lower incisor to incisal of upper incisor). 5. CROSS-BITE YES YES YES NO NO NO Anterior locked lingual tooth/teeth. Two or more teeth in same arch in posterior segment. Upper posterior tooth/teeth in buccal cross-bite to lower. 6. IMPACTIONS Please explain position and degree 7. BLOCKED OUT CANINES YES NO 8. HYPERTROPHIC GINGIVAE YES NO Direct result of excessive crowding. CONTINUED ON BACK PAGE American LegalNet, Inc. www.FormsWorkFlow.com MA 301 4/06 I M P O R TA N T COSMETIC ORTHODONTICS IS NOT COMPENSABLE IN D.P.W. REGULATIONS Please use the criteria on the opposite side at the initial examination of the patient to determine whether a handicapping malocclusion exists. If there is a handicapping malocclusion, models and x-rays can be taken and submitted to the Prior Authorization unit. PLEASE COMPLETE THE FOLLOWING Description of patient's condition and diagnosis: Treatment Plan: Remarks: MA 301 4/06 American LegalNet, Inc. www.FormsWorkFlow.com