CurrentAnthemPolicy 08-002

Non‑Medically Necessary (Cosmetic) Orthodontia

Defines coverage stance and service requirements for orthodontic care that is cosmetic/non‑medically necessary; affects providers delivering orthodontic services to Anthem members and adjudicators determining benefits under group contracts.

Policy Summary

PayerAnthem

PolicyNon‑Medically Necessary (Cosmetic) Orthodontia

Policy CodePolicy 08-002

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateJan 1, 2025

Key ActionVerify member group contract benefits and obtain any required authorizations prior to initiating non‑medically necessary orthodontic treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3types of orthodontic coverage described

11CDT codes listed or referenced

1primary subject/policy guideline

Directrequired provider supervision level

Coverage Criteria — Non‑Medically Necessary Orthodontia

Non‑Medically Necessary Orthodontia — Eligibility

Policy Summary

PayerAnthem

PolicyNon‑Medically Necessary (Cosmetic) Orthodontia

Policy CodePolicy 08-002

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateJan 1, 2025

Key ActionVerify member group contract benefits and obtain any required authorizations prior to initiating non‑medically necessary orthodontic treatment.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Contract: Benefit coverage for non‑medically necessary orthodontic therapy is determined by the member's group contract

Verify contract benefits and obtain any required authorizations per the member's contract prior to treatment

Provider qualifications: Diagnosis, treatment planning, and hands‑on treatment must be performed under the direct supervision of an actively licensed dentist or orthodontist

Direct supervision required

Pre‑treatment completion: All necessary dental procedures that may affect orthodontic treatment must be completed prior to initiation of orthodontic therapy

Sequential care required

Coding — CDT and Diagnosis Codes

CDT codes (informational)CDT

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.
D8070	Comprehensive treatment of the transitional dentition.
D8090	Comprehensive treatment of the adult dentition.
D8091	Comprehensive orthodontic treatment with orthognathic surgery.
D8660	Pre-orthodontic treatment examination to monitor growth and development.
D8670	Periodic orthodontic treatment visit.
D8671	Periodic orthodontic treatment visit associated with orthognathic surgery.

1–10 of 12

1/2

Diagnosis codesICD-10

ICD-10 CM

Diagnoses for Dental Diseases and Conditions: See the current CDT code book for details

Provider Actions — Authorization, Documentation, and Billing

Prior Authorization

Benefit/Authorization

Benefit/authorization per group contract — Verify benefits and obtain authorizations per member's group contract.

Benefit coverage for non‑medically necessary orthodontic therapy is determined by the member's group contract.
Verify member eligibility and obtain any required prior authorization/notification per the group contract before initiating services.

Note

Provider Actions — Not specified

PROVIDER ACTIONS — Not specified.

Documentation Required

Documentation and Sequencing

Required documentation and sequencing — Diagnosis, treatment planning, hands‑on treatment, pre‑treatment visit, records, periodic visits, retention and post‑treatment records should be documented.

Diagnosis, treatment plan, and all hands‑on orthodontic treatment must be under the direct supervision of an actively licensed dentist or orthodontist.
Document pre‑orthodontic treatment examination, start‑up records, comprehensive or limited orthodontic treatment records, periodic treatment visits, retention, and post‑treatment records.
All necessary dental procedures that may affect orthodontic treatment must be completed prior to initiation of orthodontic therapy.

Denial Risk

Denial Risk and Coding

PROVIDER ACTIONS — Coverage or reimbursement may be denied if the member's contract does not include non‑medically necessary orthodontia; inclusion of procedures/codes does not guarantee payment.

Inclusion of CDT or ICD‑10 codes in guidance is informational only and does not imply coverage or reimbursement.
Confirm contract terms and medical necessity where applicable; denial risk exists when services are cosmetic/non‑medically necessary and not covered by the member's plan.

Background

Cosmetic (non‑medically necessary) orthodontia is intended to improve dental appearance and may address mild to moderate malocclusion and minor dysfunctional occlusal discrepancies. Treatment goals are to achieve improved function and/or cosmetic appearance of the dentition in support of overall oral health, which can potentially reduce the risk of tooth decay, periodontal disease, tooth loss, and TMJ/TMD problems. Although these outcomes can be beneficial, determination of benefit coverage for cosmetic orthodontic therapy is made according to the member's group contract.

Definitions — Non‑Medically Necessary Orthodontia

Non‑medically necessary (cosmetic) orthodontia — definition and attributes

DefinitionOrthodontic care that is essentially cosmetic in nature and not considered medically or dentally necessary, though it may treat mild to moderate malocclusion and minor dysfunctional occlusal discrepancies.

Primary goalImprove dental appearance and/or function consistent with overall oral health, potentially reducing risk of tooth decay, periodontal disease, tooth loss, and TMJ/TMD problems.

Typical indicationsTreatment of misaligned or crowded teeth, crossbites, prognathic or retrognathic jaw appearance related to tooth malposition, and control of harmful oral habits.

Provider requirementOrthodontic and dental services must be provided by a licensed dentist or orthodontist exercising prudent clinical judgment.

Coverage controlInclusion of codes is informational only; benefit coverage for non‑medically necessary orthodontia is determined by the member's group contract.

Treatment sequencingAll necessary dental procedures that may affect orthodontic treatment should be completed prior to initiation of orthodontic therapy.