This policy document only applies to Individual and Small Group EHB Products
DESCRIPTION
Orthodontia, also known as orthodontics and dentofacial orthopedics, is a specialized branch of dentistry that focuses on the diagnosis and treatment of dental and facial irregularities. Pediatric orthodontic problems are commonly referred to as malocclusion. Malocclusion may be caused by missing teeth, extra teeth, crowded teeth and/or abnormal alignment of the jaw. Most of these pediatric problems are inherited; however, significant deviation of the teeth and/or jaw may also be caused by accidents, burns, osteomyelitis or other severe trauma. Orthodontic treatment, which involves the application of wires and orthodontic brackets (i.e., braces), is performed to correct the alignment of teeth and jaws.
POLICY
Non-cosmetic, pediatric orthodontia is considered medically necessary for the treatment of severe malocclusion if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Pediatric orthodontia is considered cosmetic for all other conditions / diseases.
MEDICAL APPROPRIATENESS
Non-cosmetic, pediatric orthodontia is considered medically appropriate if ALL of the following criteria are met:
The individual has ANY ONE of the following:
Cleft lip and/or cleft palate
Cross bite of individual anterior teeth causing destruction of soft tissue
Severe traumatic deviation (e.g., loss of premaxilla segment due to a burn, or accident, or osteomyelitis, or other gross pathology)
Developmental malformations (e.g., Crouzon’s Syndrome, Treacher-Collins Syndrome, Pierre-Robin Syndrome)
Facial disfigurement
Maxillary and/or mandibular facial skeletal deformities associated with significant malocclusion are present as evidenced by ANY ONE of the following: [Note: Medical indications relate verifiable clinical measurements to significant facial skeletal deformities.]
Anterior discrepancies with ANY ONE of the following:
Maxillary/Mandibular incisor relationship: overjet of 9mm or reverse overjet greater than 3.5mm (Note: Overjet up to 9mm may be treatable with routine cosmetic orthodontic therapy)
Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4mm or more (norm 0 to 1mm) (These values represent two or more standard deviations from published norms)
Vertical discrepancies with ANY ONE of the following:
Presence of a vertical facial skeletal deformity, which is two or more standard deviations from published norms for accepted skeletal landmarks
Open bite with ANY ONE of the following:
No vertical overlap of anterior teeth
Unilateral or bilateral posterior open bite greater than 2mm
Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch
Supra-eruption of a dentoalveolar segment due to lack of occlusion
Transverse discrepancies with ANY ONE of the following:
Presence of a transverse skeletal discrepancy, which is two or more standard deviations from published norms
Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4mm or greater, or a unilateral discrepancy of 3mm or greater, given normal axial inclination of the posterior teeth
Asymmetries with anteroposterior, transverse or lateral asymmetries greater than 3mm with concomitant occlusal asymmetry
SOURCE
DDS consultants
ORIGINAL EFFECTIVE DATE: 1/1/2017
MOST RECENT REVIEW DATE: 2/15/2024