Salzmann Evaluation Form

This form is used to evaluate the conditions that may or may not qualify patients for coverage of medically necessary orthodontic services.

Medically Necessary Orthodontia related to the Pediatric Dental Essential Benefit in the Affordable Care Act (ACA):

Comprehensive medically necessary orthodontic services are covered for members who have a severe handicapping malocclusion related to a medical condition.

Establishment of medical necessity requires documentation to support the severe handicapping malocclusion and medical condition status. To qualify for coverage, a score of 42 points or greater on the Modified Salzmann Index is needed. Documentation must include a completed Salzmann evaluation form and a written report from the attending physician, pediatrician, or qualified medical specialist(s) treating the deformity/anomaly.

For your convenience, download the Salzmann Evaluation form with instructions for completion.

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