Medically necessary orthodontia related to the pediatric dental essential benefit in the Affordable Care Act (ACA) (039)

Number: 039
(Updated)

Subject: Medically necessary orthodontia related to the pediatric dental essential benefit in the Affordable Care Act (ACA)

Review Date: April 19, 2021

Important note

This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).

Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in this Bulletin. The discussion, analysis, conclusions and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna’s opinion and are made without any intent to defame.

Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.

Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.

The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (for example, will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers 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.

Visit the CMS coverage database

Policy

Comprehensive medically necessary orthodontic services are covered for members who have a severe handicapping malocclusion related to a medical condition such as:
 

• Cleft palate or other congenital craniofacial or dentofacial malformations requiring reconstructive surgical correction in addition to orthodontic services
• Trauma involving the oral cavity and requiring surgical treatment in addition to orthodontic services
• Skeletal anomaly involving maxillary and/or mandibular structures

To be considered medically necessary (needed to treat, correct or ameliorate a medical defect or condition,) orthodontic services must be an essential part of an overall treatment plan developed by both the physician and the dentist in consultation with each other.

Establishment of medical necessity requires documentation to support the severe handicapping malocclusion and medical condition status. To qualify for coverage, a score of 42 points or greater on the Modified Salzmann Index is needed. Documentation must include a completed Salzmann assessment form and a written report from the attending physician, pediatrician, or qualified medical specialist(s) treating the deformity/anomaly. Progress notes, photographs and other relevant supporting documentation may be included as appropriate.

Orthodontic treatment for dental conditions that are primarily cosmetic in nature or when self-esteem is the primary reason for treatment does not meet the definition of medical necessity.

Background

On January 1, 2014, major parts of the Affordable Care Act (ACA) were implemented. The ACA is adding required benefits to all new health plans.¹ Aetna has been certified as a qualified health plan (QHP) in several states. As a part of the certification process Aetna will offer all 10 required essential health benefits (EHB). One of these EHB requirements is pediatric oral services, up to age 19. Guided by state benchmark plans, Aetna’s medical plans with embedded pediatric dental benefits will include medically necessary orthodontia.

Handicapping malocclusion assessment record - The Salzmann evaluation index and instructions

The Salzmann assessment record is intended to disclose whether a handicapping malocclusion is present and to assess its severity according to the criteria and weights (point values) assigned to them.^2,3 The weights are based on tested clinical orthodontic values from the standpoint of the effect of the malocclusion on dental health, function, and esthetics. Etiology, diagnosis, planning, complexity of treatment, and prognosis are not factors in this assessment. The Salzmann evaluation form and instructions are included below.

Salzmann evaluation index

Possible orthodontic codes⁴

D8010 - Limited orthodontic treatment of the primary dentition
D8020 - Limited orthodontic treatment of the transitional dentition
D8030 - Limited orthodontic treatment of the adolescent dentition
D8040 - Limited orthodontic treatment of the adult dentition
D8050 - Interceptive orthodontic treatment of the primary dentition
D8060 - Interceptive orthodontic treatment of 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

The above policy is based on the following references:

¹Department of Health and Human Services. Patient Protection and Affordable Care Act; standards related to essential health benefits, actuarial value, and accreditation.

²Agarwal, A. & Mathur, R. (2012) An overview of orthodontic indices. World Journal of Dentistry, January-March; 3(1):77-86.

³Salzmann, J.A. Handicapping malocclusion assessment to establish treatment priority. Am J Orthod 1968 Oct; 54(10) :749-65

⁴American Dental Association. CDT 2021 Dental Procedure Codes*

Please reference other Aetna Medical Policy Bulletins

Dental Clinical Policy Bulletin Number 020 - Dental services and oral and maxillofacial surgery: Coverage under medical mlans

Medical Clinical Policy Bulletin Number 0082 - Dental services and oral and maxillofacial surgery: Coverage under medical plans

*Copyright 2021 American Dental Association. All rights reserved.

Revision dates

Original policy: September 23, 2013
Update: July 23, 2014; August 25, 2015; October 20, 2016; November 13, 2017; March 4, 2020, April 19, 2021

Property of Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This 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 advice and treatment of members.