ModifiedAnthemPolicy 08-002

Orthodontia - Non-Medically Necessary Orthodontia Care

Governs coverage and clinical guidance for non‑medically necessary (cosmetic) orthodontic treatments under Anthem dental policies; applicability depends on the member's group contract and state mandates.

Policy Summary

PayerAnthem

PolicyOrthodontia - Non-Medically Necessary Orthodontia Care

Policy CodePolicy 08-002

Change TypeRevised

Effective Date01/01/2026

Next Review Date

Key ActionVerify member group contract benefits and obtain prior authorization when required before initiating non‑medically necessary orthodontic treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3types of orthodontic coverage described

12+CDT orthodontic codes listed

Directprovider supervision requirement

Requiredpre‑treatment completion

Coverage Criteria for Non‑Medically Necessary Orthodontia

Non‑medically necessary orthodontia coverage criteria

Policy Summary

PayerAnthem

PolicyOrthodontia - Non-Medically Necessary Orthodontia Care

Policy CodePolicy 08-002

Change TypeRevised

Effective Date01/01/2026

Next Review Date

Key ActionVerify member group contract benefits and obtain prior authorization when required before initiating non‑medically necessary orthodontic treatment.

SourceLink

On This Page

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Provider requirement: Orthodontia and dental services must be provided by a licensed dentist or orthodontist exercising prudent clinical judgment

Direct supervision required for diagnosis, treatment planning, and hands‑on treatment.

Purpose of treatment: Provided for preventing, evaluating, diagnosing or treating orthodontic problems such as misaligned or crowded teeth, teeth in cross bite, prognathic or retrognathic jaw appearance due to malposition of the teeth, or control of harmful habits

Cosmetic care is appropriate for mild to moderate malocclusion and minor dysfunctional occlusal discrepancies.

Goal of treatment: Goal is to improve function and/or cosmetic appearance consistent with supporting overall health to decrease risk of tooth decay, gingival/periodontal disease, tooth loss, and/or TMJ/TMD problems

Coverage categories and interactions

Coverage determination depends on plan type and state mandates:

State mandated medically necessary orthodontia: State mandated treatment for medically necessary orthodontia may apply per law

Group contract and state law take precedence.

Medically necessary per plan: Orthodontia considered medically necessary according to plan guidelines may be covered under a different determination

Distinct from cosmetic/non‑medically necessary benefits.

Cosmetic orthodontia is generally not considered medically necessary or dentally necessary treatment

Coverage for cosmetic orthodontia is subject to the member's group contract benefits.

Cosmetic orthodontia care is not considered medically or dentally necessary treatment. Orthodontia and dental services for non‑medically necessary (cosmetic) cases must be provided by a licensed dentist or orthodontist exercising prudent clinical judgment and are intended to prevent, evaluate, diagnose, or treat orthodontic problems such as misaligned or crowded teeth, cross bite, prognathic/retrognathic jaw appearance due to tooth malposition, or the control of harmful habits.

CDT Orthodontic Procedure Codes (Informational)

CDT orthodontic procedure 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
D8080	Comprehensive treatment of the adolescent 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

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Provider Requirements, Prior Authorization, and Denial Risk

Prior Authorization

Prior authorization tied to member contract

Coverage for non-medically necessary (cosmetic or elective) orthodontic therapy is determined by the member’s group contract. Prior authorization requirements, if any, and whether orthodontic services are a covered benefit depend on the specific terms and exclusions in the member’s contract in effect at the time of service. Providers must verify benefits and prior authorization requirements with the payer before initiating treatment.

Verify member contract benefits and prior authorization requirements prior to treatment initiation.
Prior authorization may be required when specified by the group contract.

Denial Risk

Contract-based coverage denial risk

Benefit coverage for non‑medically necessary orthodontia may be denied if the member’s group contract does not include coverage for cosmetic or elective orthodontic services. Even when services are clinically appropriate, payment is subject to the terms, limitations, and exclusions of the member’s contract.

Services may be denied or deemed not covered if the member’s contract excludes non‑medically necessary or cosmetic orthodontia.
Always confirm covered benefits, limitations, and exclusions in the member’s contract before providing or billing for services.

Documentation Required

Provider and documentation requirements

Diagnosis, treatment planning, and hands‑on orthodontic treatment must be performed by, or under the direct supervision of, an actively licensed dentist or orthodontist. Documentation in the member’s record should include diagnostic findings, treatment plan, informed consent, start‑up records, periodic treatment notes, retention plan, and post‑treatment records as applicable.

Maintain complete clinical documentation: exam findings, diagnostic records (models, radiographs, photos), start‑up records, treatment plan, progress notes, retention/retainer documentation, and post‑treatment records.
Provider must be an actively licensed dentist or orthodontist; hands‑on care must occur under direct supervision.
Documentation must support medical necessity when applicable and align with billed CDT/diagnosis codes.

Documentation Required

Completion of prerequisite dental care

All dental procedures that could affect orthodontic outcomes must be completed prior to starting orthodontic therapy. This includes restorative work, extractions, periodontal therapy, and any other necessary dental treatment that may influence orthodontic planning or results.

Complete prerequisite dental care (restorations, extractions, periodontal treatment, endodontic therapy, etc.) before initiating orthodontic treatment.
Ensure outstanding dental issues that could compromise orthodontic outcomes are addressed and documented in the record.

Background

Non‑medically necessary (cosmetic) orthodontia, while typically considered cosmetic, can nevertheless provide functional benefits and support overall oral health. The stated goals include improving function and/or cosmetic appearance to decrease risks of tooth decay, gingival/periodontal disease, tooth loss, and TMJ/TMD problems. Indications for treatment include correcting misaligned or crowded teeth, cross bites, prognathic or retrognathic jaw appearance related to tooth position, and control of harmful habits; all services must be delivered by a licensed dentist or orthodontist exercising prudent clinical judgment.

Definitions

Cosmetic orthodontia / Non‑medically necessary orthodontia — definition

Primary intentOrthodontic treatment primarily intended to improve cosmetic appearance or to treat mild to moderate malocclusion that is not classified as medically necessary; may still provide functional benefits and reduce future oral health risks.

Examples of clinical problems addressedMisaligned (crooked) or crowded teeth; teeth in cross bite; prognathic or retrognathic jaw appearance due to tooth malposition; control of harmful oral habits.

Coverage characterizationCosmetic orthodontia care is not considered medically or dentally necessary treatment; coverage for non‑medically necessary orthodontia is subject to the member's group contract and applicable state mandates.

Treatment goalsImprove function and/or cosmetic appearance to support overall health and decrease risk of tooth decay, gingival/periodontal disease, tooth loss, and TMJ/TMD problems.

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