Medical Necessity and Orthodontic Treatment

Orthodontic treatment is common for many children, especially for middle and high school age patients. One major concern for a patient when electing to receive orthodontic treatment is whether or not the treatment will be covered by insurance.

Now that the Affordable Care Act (ACA) requires that children under the age of 19 are offered dental coverage, some may assume that all orthodontic treatment will automatically be covered. However, this is not always the case. When determining if orthodontic treatment will be covered, it is important to know if it is considered medically necessary. Keep in mind that only about 15 percent of orthodontic cases are 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 physical or emotional health may require medically necessary orthodontic treatment.

All parties involved typically experience some confusion about medical necessity. 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. Finally, there seems to be confusion among payers regarding the meaning of medical necessity in relation to orthodontic treatment and which treatments are actually covered.

With the confusion about medical necessity, it has been proposed that some auto-qualifiers be considered. The autoqualifiers include 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, and so on.

Once it is determined that the treatment could qualify for coverage, 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 requirements. 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 considered to be esthetic in nature, and not medically necessary. When submitting claims for medically necessary cases, be sure to enclose all of the documentation needed to support the necessity of the treatment.