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Orthodontic decision checklist 2026

The document is an Orthodontic Decision Checklist from the Commonwealth of Pennsylvania's Department of Public Welfare, designed to assess whether a patient has a handicapping malocclusion that qualifies for prior authorization. It includes criteria for evaluating dental conditions such as overbite, open-bite, overjet, cross-bite, impactions, blocked out canines, and hypertrophic gingivae. The document emphasizes that cosmetic orthodontics is not covered under D.P.W. regulations and outlines the necessary steps for submitting cases for approval.

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Click ‘Get Form’ to open the orthodontic decision checklist in the editor.
Begin by entering the recipient's name and ID number at the top of the form. This information is crucial for identifying the patient.
Proceed to section 1, where you will indicate whether permanent teeth are fully erupted by selecting 'YES' or 'NO'.
In section 2, assess the overbite condition. Mark 'YES' or 'NO' based on your evaluation, and provide additional details if necessary.
Continue to section 3 for open-bite assessment. Again, select 'YES' or 'NO', and note any specific observations regarding anterior or posterior open-bites.
For section 4 on overjet, simply mark your findings as 'YES' or 'NO'.
In section 5, evaluate cross-bite conditions and respond accordingly.
Complete sections on impactions, blocked out canines, and hypertrophic gingivae by providing detailed explanations where required.
Finally, fill out the description of the patient's condition and diagnosis along with a treatment plan in the designated areas.

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