Download Medically Necessary Orthodontic Treatment

UnitedHealthcare ® Dental
Coverage Guideline
MEDICALLY NECESSARY ORTHODONTIC TREATMENT
Guideline Number: DC G003.02
Table of Contents
Page
INSTRUC TIONS FOR USE ............................................1
BENEFIT C ONSIDERATIONS ........................................1
C OVERAGE RATIONALE ..............................................1
DEFINITIONS ............................................................2
APPLIC ABLE C ODES ...................................................3
DESC RIPTION OF SERVIC ES .......................................4
REFERENC ES.............................................................4
GUIDELINE HISTORY/REVISION INFORMATION ............4
Effective Date: January 1, 2017
Related Dental Policy

Imaging Services: C one Beam C omputed
Tomography
Related Medical Policy

Orthognathic (Jaw) Surgery
INSTRUC TIONS FOR USE
This Dental C overage Guideline provides assistance in interpreting UnitedHealthcare dental benefit plans. When
deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific
benefit plan document [e.g., C ertificate of C overage (C OC), Schedule of Benefits (SOB), and/or Summary Plan
Description (SPD)] may differ greatly from the standard benefit plan upon whi ch this Dental C overage Guideline is
based. In the event of a conflict, the member specific benefit plan document supersedes this Dental C overage
Guideline. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the
member specific benefit plan coverage prior to use of this Dental C overage Guideline. Other C linical Policies and
C overage Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and
Guidelines as necessary. This Dental C overage Guideline is provided for informational purposes. It does not constitute
medical advice.
BENEFIT C ONSIDERATIONS
Before using this guideline, please check the member specific benefit plan document and any federal or state
mandates, if applicable.
Essential Health Benefits for Individual and Small Group
For plan years beginning on or after January 1, 2014, the Affordable C are Act of 2010 (AC A) requires fully insured
non-grandfathered individual and small group health plans (inside and outside of Exchanges) to provide coverage for
Pediatric Dental Essential Health Benefits (“EHBs”). Large group plans (both self -funded and fully insured), and small
group ASO plans, are not subject to the requirem ent to offer coverage for Pediatric Dental EHBs. However, if such
plans choose to provide coverage for benefits which are deemed Pediatric Dental EHBs, the AC A requires all dollar
limits on those benefits to be removed on all Grandfathered and Non -Grandfathered plans. The determination of which
benefits constitute Pediatric Dental EHBs is made on a state by state basis. As such, when using this guideline, it is
important to refer to the member specific benefit plan document to determine benefit coverage.
C OVERAGE RATIONALE
Indications for Coverage
Orthodontic treatment is a covered dental service and medically necessary when the following criteria have been met :

All services must be approved by the plan; and

The member is under the age 19 (through age 18, unless the benefit plan document indicates a different age);
and

Services are related to one of the following conditions:
o C left lip and/or cleft palate;
o C rouzon’s Syndrome;
o Treacher-C ollins Syndrome;
o Pierre-Robin Syndrome;
o Hemi-facial atrophy;
o Hemi-facial hypertrophy;
o Severe craniofacial deformities that result in a physically handicapping malocclusion; or
Me dically Ne cessary Orthodontic Treatment
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o
Other clinical criteria based on state specific language
Required Documentation
All




of the following documentation must be received:
Panoramic imaging
C ephalometric imaging
5-7 intraoral photographs
Other forms as required by the state
Coverage Limitations and Exclusions

Orthodontic services that do not meet the criteria listed above

Orthodontic services that are specifically excluded

Orthodontic services for crowded dentitions (crooke d teeth), excessive spacing between teeth, temporomandibular
joint (TMJ) conditions and/or horizontal/vertical discrepancies (overjet/overbite)
DEFINITIONS
Cleft Lip: A congenital facial defect of the lip due to failure of fusion of the medial and latera l nasal prominences and
maxillary prominence (American C left Palate-C raniofacial Association)
Cleft Palate: A congenital fissure in the medial line of the palate (American C left Palate -C raniofacial Association)
Comprehensive Orthodontic Treatment: A coordinated approach to improvement of the overall anatomic and
functional relationships of the dentofacial complex, as opposed to partial correction with more limited objectives such
as cosmetic improvement. Usually but not necessarily uses fixed orthodontic attachments as a part of the treatment
appliance. Includes treatment and adjunctive procedures, such as extractions, maxillofacial surgery, other dental
services, nasopharyngeal surgery, and speech therapy, directed at malrelationships within the entire dentofacial
complex. (Farlex Partner Medical Dictionary)
Craniofacial Anomaly: A structural or functional abnormality that affects the cranium or face (American C left Palate C raniofacial Association)
Crouzon Syndrome: Malformations of the skull and face, ocular proptosis sometimes so severe that the eyes
protrude outside the orbital rims (American C left Palate -C raniofacial Association)
Hemifacial Atrophy : An uncommon degenerative condition characterized by atrophic changes affecting one side of
the face. The condition is usually sporadic but a few familial cases have been reported suggesting a possible
hereditary influence. The onset of the syndrome is usually during the first two decades of life. The condition begins as
atrophy of the skin and subcutaneous structures in a localized area of the face. This atrophy progresses at a variable
rate and affects the dermatome of one or more branches of the trigeminal nerve. Hypoplasia of the underlying bone
may also occur. Hemifacial Atrophy is also known as Romberg Syndrome or Parry-Romberg Syndrome.
Hemifacial Hypertrophy: A type of hemi-hyperplasia or hemi-hypertrophy. Hemi-hyperplasia is a rare
developmental anomaly characterized by unilateral enlargement of the body. Although the condition is known more
commonly as hemi-hypertrophy, it actually represents a hyperplasia of the tissues rather than a hypertrophy. In a
person with hemi-hyperplasia, one whole side of the body may be affected or the enlargement may be limited to a
single digit or limb. If the enlargement is confined to one side of the face, the term Hemifacial Hypertrophy may apply.
Hemifacial Hypertrophy can impact all facial structures in the affected area or, in cases of partial Hemifacial
Hyertrophy, not all structures will be enlarged. The condition can occasionally be crossed and involve different areas
on both sides of the body.
Handicap (as Related to Handicapping Malocclusion): A physical, mental, or emotional condition that interferes
with one's normal functioning. (Farlex Partner Medical Dictionary)
Medically Necessary : The health care services provided for the purpose of preventing, evaluating, diagnosing or
treating a sickness, injury, mental illness, substance use disorder, condition, disease or its symptoms, that are all of
the following as determined by us or our designee, within our sole discretion.

In accordance with Generally Accepted Standards of Medical Practice.

C linically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your
sickness, injury, mental illness, substance use disorder, disease or its symptoms.

Not mainly for your convenience or that of your doctor or other health care provider.

Not more costly than an alternative drug, service(s) or supply that is at least as likely to p roduce equivalent
therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or symptoms.
Me dically Ne cessary Orthodontic Treatment
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Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence
published in peer-reviewed medical literature generally recognized by the relevant medical community, relying
primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that
suggest a causal relationship between the service or treatment and health outcomes.
If no credible scientific evidence is available, then standards that are based on Physician specialty society
recommendations or professional standards of care may be considered. We reserve the right to consul t expert opinion
in determining whether health care services are Medically Necessary. The decision to apply Physician specialty society
recommendations, the choice of expert and the determination of when to use any such expert opinion, shall be within
our sole discretion.
We develop and maintain clinical policies that describe the Generally Accepted Standards of Medical Practice scientific
evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding specific
services. These clinical policies (as developed by us and revised from time to time), are available to C overed Persons
on [www.myuhc.com] or by calling C ustomer C are at the telephone number on your ID card, and to Physicians and
other health care professionals on UnitedHealthcareOnline. (C OC , 2011)
Malocclusion (as Related to Handicapping Malocclusion): A problem in the way the upper and lower teeth fit
together in biting or chewing. The word malocclusion literally means "bad bite." The condition may also be ref erred to
as an irregular bite, crossbite, or overbite. (Gale Encyclopedia)
Pierre-Robin Sequence: A complex of congenital anomalies including micrognathia and abnormal smallness of the
tongue, often with cleft palate, severe myopia, congenital glaucoma, a nd retinal detachment. (American C left PalateC raniofacial Association)
Progressive Hemifacial Atrophy (Parry-Romberg Syndrome): C haracterized by one side of the face becoming
progressively sunken and wrinkled over 2 to 20 years and then stabilizing. The average onset of disease is 10 years
old, but progressive hemifacial atrophy can occur as early as infancy or as late as age 40 to 50 years. The severity of
progressive hemifacial atrophy varies greatly. (National Institutes of Health)
Treacher-Collins Syndrome: A condition that affects the development of bones and other tissues of the face. The
signs and symptoms of this disorder vary greatly, ranging from almost unnoticeable to severe. Most affected
individuals have underdeveloped facial bones, particular ly the cheek bones, and a very small jaw and chin
(micrognathia). Some people with this condition are also born with an opening in the roof of the mouth called a cleft
palate. In severe cases, underdevelopment of the facial bones may restrict an affected i nfant's airway, causing
potentially life-threatening respiratory problems. (U.S. National Library of Medicine)
APPLIC ABLE C ODES
The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all
inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non covered health service. Benefit coverage for health services is determined by the member specific benefit plan
document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply
any right to reimbursement or guarantee claim payment. Other C linical Policies and C overage Guidelines may apply.
C DT C ode
D8050
Description
interceptive orthodontic treatment of the primary dentition
D8060
interceptive orthodontic treatment of the transitional dentition
D8070
comprehensive orthodontic treatment of the transitional dentition
D8080
comprehensive orthodontic treatment of the adolescent dentition
D8090
comprehensive orthodontic treatment of the adult dentition
D8220
fixed appliance therapy
D8660
pre-orthodontic treatment examination to monitor growth and development
D8670
periodic orthodontic treatment visit
D8680
orthodontic retention (removal of appliances, construction and placement of
retainer(s))
D8690
orthodontic treatment (alternative billing to a contract fee)
D8691
repair of orthodontic appliance
Me dically Ne cessary Orthodontic Treatment
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C DT C ode
D8999
Description
unspecified orthodontic procedure, by report
CDT® is a registered trademark of the American Dental Association
DESC RIPTION OF SERVIC ES
Medically necessary orthodontic treatment involves the correction of the dental component of a craniofacial
abnormality that results in a handicapping malocclusion. It is intended to restore a functional den tition.
REFERENC ES
American Association of Orthodontists C linical Practice Guidelines for Orthodontics and Dentofacial Orthopedics 2014.
Available at:
https://www.aaoinfo.org/system/files/media/documents/2014%20C llinical%20Practice%20Guidelines.pdf . Accessed
September 19, 2016
American C left Palate – C raniofacial Association. SLP C left Palate Terminology available at:http://www.acpacpf.org/education/educational_resources/professional_enhancement_resources/slp_cleft_palate_terminology .
Accessed September 19, 2016
Farlex Partner Medical Dictionary. (2012). Available at: http://medical-dictionary.thefreedictionary.com Accessed
September 19, 2016
Gale Encyclopedia of Medicine. (2008). http://medical-dictionary.thefreedictionary.com/malocclusion. Accessed
September 19, 2016
Information on Essential Health Benefits (EHB) Benchmark Plans (links to States plans) Available at:
https://www.cms.gov/cciio/resources/data-resources/ehb.html. Accessed September 19, 2016
National Institutes of Health, US National Library of Medicine, Genetics Home Reference. (2016 ). Available at:
https://ghr.nlm.nih.gov/condition/treacher-collins-syndrome Accessed September 19, 2016
National Institutes of Health, National C enter for Advancing Translational Science, Genetic and Rare Diseases
Information C enter. Available at: https://rarediseases.info.nih.gov/diseases/7338/progressive -hemifacial-atrophy
Accessed September 19, 2016
GUIDELINE HISTORY/REVISION INFORMATION
Date

01/01/2017



Action/Description
Updated definitions:
o Added definition of:

C left lip

C left palate

C raniofacial anomaly

Pierre-Robin sequence

Progressive hemifacial atrophy (Parry -Romberg syndrome)
o Removed definition of:

C left lip/cleft palate

C raniofacial disorder or craniofacial anomaly

Pierre-Robin syndrome
o Revised definition of:

C omprehensive orthodontic treatment

C rouzon syndrome

Handicap (as related to handicapping malocclusion)

Treacher-C ollins syndrome
Updated list of applicable C DT codes; revised description for D8660 and D8670
Updated supporting information to reflect the most current references
Archived previous policy version DC G003.01
Me dically Ne cessary Orthodontic Treatment
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