CurrentAnthemPolicy 08-001

Medically Necessary Orthodontia Care (MNOC)

Defines clinical criteria, documentation, and coding guidance for determining medical necessity of orthodontic treatment for severe handicapping malocclusions; applies to members/contracts subject to medical necessity review by the plan.

Policy Summary

PayerAnthem

PolicyMedically Necessary Orthodontia Care (MNOC)

Policy CodePolicy 08-001

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionObtain pre-authorization and submit the required documentation including completed HLD Scoring Index, treatment plan, radiographs, and photographs before initiating MNOC services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥26HLD threshold

10Required docs

CDT listInformational codes

AutomaticAutomatic qualifiers

Coverage Criteria

Medically Necessary Orthodontia Care (MNOC)

Covered when ALL of the following are met:

Provider and purpose: Orthodontia and dental services must be provided by a licensed dentist or orthodontist, exercising prudent clinical judgment, and provided to a patient for the purpose of preventing, evaluating, diagnosing or treating orthodontic problems.

Pre-authorization is required prior to initiation of any services.

Dentition status: Patient must present with fully erupted permanent teeth; if partially erupted or impacted due to severe crowding, the tooth must show exposure of at least three-quarters (3/4) of the clinical crown.

Index score: Validated, recognized index criteria must be used and the subscriber must achieve a Handicapping Labio-Lingual Deviation (HLD) Index minimum score of 26 points (or the threshold set by the state/group). Handicapping esthetic diagnoses are not considered in this determination.

Policy Summary

PayerAnthem

PolicyMedically Necessary Orthodontia Care (MNOC)

Policy CodePolicy 08-001

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionObtain pre-authorization and submit the required documentation including completed HLD Scoring Index, treatment plan, radiographs, and photographs before initiating MNOC services.

SourceLink

On This Page

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Coding and Indices

CDT codes (informational)CDT

D8660	Pre-orthodontic treatment examination to monitor growth and development.
D8030	Limited orthodontic treatment of the adolescent dentition.
D8040	Limited orthodontic treatment of the adult dentition.
D8080	Comprehensive treatment of the adolescent dentition.
D8090	Comprehensive treatment of the adult dentition.
D8670	Periodic orthodontic treatment visit.
D8693	Re-cement or re-bond fixed retainer.
D7280	Surgical access of an unerupted tooth.
D7283	Placement of device to facilitate eruption of impacted tooth.

HLD Index threshold

HLD Index threshold>= 26 points (or threshold set by state/group)

Index used for qualificationValidated, recognized HLD (Handicapping Labio-Lingual Deviation) Scoring Index

Exception/alternative thresholdState- or group-specific threshold may apply instead of 26 points

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required

MNOC services require pre-authorization prior to initiation of any orthodontic services. Providers must obtain authorization before scheduling or beginning treatment to avoid claim denials or nonpayment.

Pre-authorization required prior to initiation of any Medically Necessary Orthodontia Care (MNOC) services.

Documentation Required

Pre-authorization Documentation Required

Providers must submit complete documentation as part of the pre-authorization request. Incomplete submissions may delay review or result in denial.

Completed HLD (Handicapping Labio-Lingual Deviation) Scoring Index
Orthodontic treatment plan
Narrative describing the severe physically handicapping malocclusion
Panoramic and/or mounted full mouth radiographs
Cephalometric x-ray with cephalometric tracing
Facial photographs (frontal and profile)
Intra-oral photographs (right/left occlusal relationships and anterior view)
Maxillary and mandibular occlusal photographs
Photographs of articulated study models or ortho CAD/CAM electronic equivalent (lateral, anterior, posterior views)
If surgery is planned: surgical treatment plan and letter of medical necessity

Note

Provider Action Items

Providers should take the following action items to ensure timely review and authorization.

Verify the member’s plan benefits and contract-specific requirements before submitting a pre-authorization request
Obtain and submit all required clinical documentation listed under pre-authorization requirements
Ensure treating clinician is a licensed dentist or orthodontist and documents clinical judgment and indication for treatment
Confirm patient meets dentition requirements (fully erupted permanent teeth or ≥¾ clinical crown exposure for partially erupted/impacted teeth) and HLD index threshold

Denial Risk

Denial Risk / Contract Limitation Warning

Services that do not meet the policy criteria, lack required pre-authorization, or are outside the member’s contract provisions may be denied. Failure to obtain pre-authorization or submit required documentation increases risk of denial or nonpayment.

Services without pre-authorization are at risk of denial
Requests lacking the required documentation listed may be delayed or denied
A determination of medical necessity does not guarantee coverage if the member’s contract excludes the service

Background

Medically Necessary Orthodontia Care (MNOC) addresses severe handicapping malocclusions — conditions that substantially interfere with function such as mastication, speech, or the ability to maintain oral hygiene. These cases often require combined pre‑surgical orthodontics and surgical correction, and examples include cleft palate, severe open bite deformities, severe Class II with palatal impingement, severe Class III (underbite), Treacher Collins syndrome, and severe dento‑facial trauma. The policy notes that documented craniofacial deformities that create a handicapping malocclusion are automatic qualifiers for MNOC because of the functional impairments and potential adverse health consequences if left untreated.

Definitions

Definition: Handicapping malocclusion

Functional interferenceA malocclusion that severely interferes with function (mastication, speech, ability to maintain good oral hygiene)

Relation to pre-surgical careMany handicapping malocclusions require combined pre-surgical orthodontics and surgery; severe cases often cannot be corrected by orthodontics alone

Typical diagnosesIncludes cleft palate, severe open bite deformities, severe Class II with palatal impingement, severe Class III, Treacher Collins syndrome, severe dento-facial trauma

Generally accepted standards of dental practice

Evidence baseStandards based on credible scientific evidence published in peer‑reviewed dental literature recognized by the practicing dental community

Specialty recommendationsIncorporates specialty society recommendations/criteria

Expert opinionIncludes the views of recognized dentists practicing in the relevant clinical area

Other credible sourcesMay include other relevant factors from credible sources when applicable