Subject: Tooth positioners for orthodontic treatment
Date: April 20, 2015
This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions based on a review of currently available clinical information including:
We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.
Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to refer to the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.
A system utilizing aligners may be considered by Aetna as comprehensive orthodontic treatment. The proposed tooth movement and stage of development governs the assignment of the appropriate code.
Orthodontic aligners are a treatment modality used for the correction of malpositioned teeth. The total treatment time may vary based on factors such as the difficulty of each individual case and/or system used.
D8020 — Limited orthodontic treatment of the transitional dentition
D8030 — Limited orthodontic treatment of the adolescent dentition
D8040 — Limited orthodontic treatment of the adult 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
Original: November 22, 2005
Updated: March 29, 2010; April 9, 2012; April 30, 2013; April 17, 2014; April 20, 2015
Revision: November 20, 2006; April 29, 2008; March 30, 2009; March 14, 2011
The above policy is based on the following references:
1American Dental Association. CDT 2015 Dental Procedure Codes: 79-80.*
2Invisalign website. Align Technology, Inc. San Jose, California. Available at: http://www.invisalign.com. Accessed April 20, 2015.
3Joffe L. Invisalign: early experiences. J.Orthod. 2003 Dec; 30:348-52.
4Hajeer MY, Millett DT, Ayoub AF, Siebert JP. Applications of 3D imaging in orthodontics: part II. J. Orthod. 2004 Jun; 31:154-62.
*Copyright 2014 American Dental Association. All rights reserved.
Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.