May 2022 Volume LVII Number 3


Medical Necessity and Orthodontics

September 2016 Volume LI Number 5

Children, especially middle and high school age patients, often require orthodontic treatment. One important concern for a patient/ parent electing to receive orthodontic treatment is whether or not the treatment will be a benefit covered by insurance.

The Affordable Care Act (ACA) now requires that children under the age of 19 be offered dental coverage. One could assume that all orthodontic treatment will automatically be covered. However, this is not always true. For orthodontic treatment to be covered, it often must be considered medically necessary.

In order for orthodontics to be considered medically necessary, the case should include the treatment of craniofacial abnormalities, malocclusions caused by trauma, or craniofacial disharmonies. Also, treatment may be covered when provided in conjunction with other medical issue(s), such as a syndrome, trauma, etc. For example, a severe handicapping malocclusion which impairs a patient’s physi- cal or emotional health may require medically necessary orthodontic treatment.

Confusion about medical necessity is common. Many patients are not clear about the coverage that they have and when it will cover treatment. Also, dentists often face difficulty when filing claims in the new ACA environment. In addition, there seems to be confusion among payers regarding the meaning of medical necessity in relation to orthodontic treatment and what treatments are actually covered.

The American Association of Orthodontists (AAO) most recently promoted a list of auto-qualifiers, conditions such as: overjet and reverse overjet of a given measurement, a posterior crossbite with no functional occlusal contact, defects of cleft lip or palate, congenitally missing teeth, etc., any one of which constitutes medical necessity.

More information on AAO’s move away from index systems can be accessed at dardize-medically-necessary-orthodontic-care-criteria. In addition, the AAPD Pediatric Oral Health Research and Policy Center (POHRPC) is in the process of developing a global Policy Brief on Medical Necessity

Once it is determined that the treatment could qualify for cover- age, it is vital that the proper documentation is submitted to the payer in order to gain reimbursement. First, the doctor should perform a comprehensive orthodontic assessment based on the payer’s require- ments. Radiographs and photographs (such as cephalometric images, panoramic radiographs, and intraoral and extraoral radiographs) should be taken to support the need for treatment. These images should be submitted along with the assessment to help the payer reach the same conclusion about medical necessity.

Remember, medical necessity and orthodontic treatment do not go hand in hand. About 85 percent of orthodontic treatment is consid- ered to be esthetic in nature, and not medically necessary. When sub- mitting claims for medically necessary cases, be sure to enclose all of the documentation needed to support the necessity of the treatment.

For more information, contact Dental Benefits Director Mary Essling at (312) 337-2169 or

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