Medical Necessity

Throughout this issue of Insurance Solutions Newsletter, we have discussed medical necessity. It is important to realize that medical necessity is determined by the payer. Different organizations have different definitions of medical necessity and this can impact the payer’s definition as it relates to a particular dental procedure.

The American Dental Association

The American Dental Association (ADA) defines Medically Necessary Care as:

The reasonable and appropriate diagnosis, treatment, and follow-up care (including supplies, appliances and devices) as determined and prescribed by qualified, appropriate health care providers in treating any condition, illness, disease, injury, or birth developmental malformations. Care is medically necessary for the purpose of: controlling or eliminating infection, pain, and disease; and restoring facial configuration or function necessary for speech, swallowing or chewing.

The American Association of Orthodontists

The American Association of Orthodontists (AAO) defines Medically Necessary Care as:

Medically necessary orthodontic care is defined as the treatment of a malocclusion (including craniofacial abnormalities/ anomalies) that compromise the patient’s physical, emotional or dental health. This treatment should be based on a comprehensive assessment and diagnosis done by an orthodontist, in consultation with other health care providers when indicated.

The American Academy of Pediatric Dentistry

The American Academy of Pediatric Dentistry (AADP) defines Medically Necessary Care as:

Medically necessary care (MNC) is the reasonable and essential diagnostic, preventive, and treatment services (including supplies, appliances, and devices) and followup care as determined by qualified health care providers in treating any condition, disease, injury, or congenital or developmental malformation to promote optimal health, growth, and development ...

Dental care is medically necessary to prevent and eliminate orofacial disease, infection, and pain, to restore the form and function of the dentition, and to correct facial disfiguration or dysfunction.