CurrentAnthemPolicy 08-002

Orthodontia — Non‑Medically Necessary (Cosmetic) Orthodontia Care

Defines Anthem's approach to review and benefit qualification for non‑medically necessary (cosmetic) orthodontic care, including who may provide services and what types of orthodontia are recognized; intended for providers and claims reviewers.

Policy Summary

PayerAnthem

PolicyOrthodontia — Non‑Medically Necessary (Cosmetic) Orthodontia Care

Policy CodePolicy 08-002

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

Key ActionEnsure diagnosis, treatment planning, and hands‑on orthodontic treatment are performed by a licensed dentist or orthodontist under direct supervision and complete any dental procedures that may affect orthodontic care before starting therapy.

SourceLink

3types of orthodontic coverage listed

12+CDT codes enumerated

08-002guideline number

Directsupervision requirement

Coverage Criteria for Orthodontic Services

Types of Orthodontic Coverage

Coverage stance and qualification categories

Orthodontia coverage categories: One of three coverage types applies: (1) State mandated treatment for medically necessary orthodontia; (2) Orthodontia considered medically necessary according to plan guidelines; (3) Cosmetic orthodontia (non‑medically necessary).

Listed in document

Non‑Medically Necessary Orthodontia Criteria

Conditions for provider and treatment qualification for non‑medically necessary (cosmetic) orthodontia

Provider and treatment prerequisites: Orthodontia and dental services must be provided by a licensed dentist or orthodontist exercising prudent clinical judgment; diagnosis, treatment planning, and hands‑on treatment must occur under direct supervision of an actively licensed dentist or orthodontist; all necessary dental procedures that may affect orthodontic treatment must be completed prior to initiation of orthodontic therapy.

Applies to cosmetic/non‑medically necessary care

Policy Summary

PayerAnthem

PolicyOrthodontia — Non‑Medically Necessary (Cosmetic) Orthodontia Care

Policy CodePolicy 08-002

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

SourceLink

On This Page

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Clinical Indications

Clinical intent and scope

Clinical problems addressed: Orthodontic treatment can address misaligned or crowded teeth, teeth in crossbite, prognathic and retrognathic jaw appearance resulting from tooth malposition, and control of harmful habits. Cosmetic (non‑medically necessary) orthodontia is not considered medically or dentally necessary but may be appropriate for treatment of mild to moderate malocclusion and minor dysfunctional occlusal discrepancies to improve function and/or cosmetic appearance and reduce future dental/TMJ risk.

Document states cosmetic care is not medically necessary but may address mild/moderate issues

Cosmetic (non‑medically necessary) orthodontia is explicitly excluded as medically or dentally necessary when its primary purpose is to improve appearance. The policy clarifies that while orthodontic care may be appropriate for treating mild to moderate malocclusion and minor occlusal discrepancies, such care is considered cosmetic and not medically necessary under plan guidelines. Coverage for non‑medically necessary orthodontic therapy is governed by the member's group contract and may require prior review or be subject to exclusion.

Although not considered medically necessary, cosmetic orthodontic treatment aims to improve function and/or appearance of the dentition and may reduce risks such as tooth decay, gingival or periodontal disease, tooth loss, and TMJ/TMD problems; these potential benefits do not change the policy stance that cosmetic orthodontia is non‑medically necessary under the plan.

Provider Responsibilities and Documentation

Documentation Required

Provider and benefit qualification

To qualify for benefits, the diagnosis, treatment planning, and hands‑on orthodontic treatment must be performed by an actively licensed dentist or orthodontist and provided under their direct supervision. Documentation must show the supervising provider's licensure and involvement in diagnosis, treatment planning, and any hands‑on procedures.

Provider must be an actively licensed dentist or orthodontist
Orthodontic diagnosis, treatment planning, and hands‑on treatment performed under direct supervision

Note

Pre‑treatment completion requirement

All necessary dental procedures that may affect orthodontic treatment (for example: extractions, restorations, periodontal therapy, or endodontic work) must be completed prior to initiation of orthodontic therapy to ensure appropriate sequencing of care and to avoid denials for services that would alter the planned orthodontic outcome.

Documentation Required

Record and coding documentation

Diagnosis, treatment planning, start‑up and post‑treatment records, and documentation of periodic treatment visits are required as standard benefit documentation. Records should include exam findings, treatment plan, informed consent, start‑up records (models, photographs, radiographs as applicable), progress notes for periodic visits, and post‑treatment/retention records.

Include exam findings, treatment plan, informed consent
Start‑up records: models, photographs, radiographs (as applicable)
Periodic visit progress notes and post‑treatment/retention records

Denial Risk

PROVIDER ACTIONS — Services not meeting contractual or generally accepted standards may be denied; cosmetic (non‑medically necessary) treatments subject to denial

Services that do not meet contractual requirements or generally accepted standards of dental care, or that are cosmetic (non‑medically necessary), may be denied. Providers should ensure documentation supports medical/dental necessity and that requested services align with the member's benefit contract; absence of such documentation or services provided outside acceptable standards of care are subject to denial.

Services not meeting contract terms or generally accepted standards may be denied
Cosmetic or non‑medically necessary orthodontic treatments are subject to denial
Ensure documentation demonstrates medical/dental necessity and conformity with member contract

Definitions and Standards

Generally accepted standards of dental care

DefinitionStandards based on credible scientific evidence published in peer-reviewed dental literature, the views of recognized practicing dentists in the relevant clinical area, specialty society recommendations/criteria, and other relevant credible sources.

PurposeApply to dental services provided by a dentist exercising prudent clinical judgment for evaluating, diagnosing, or treating dental injury, disease or symptoms in terms of type, frequency and extent considered effective for the patient.

ScopeIncludes standards for determining if services are not primarily for the convenience of the patient or dentist and align with generally accepted standards of dental practice.

Use in coverage decisionsBenefit coverage for non-medically necessary orthodontic therapy is subject to the member's group contract and evaluated against these standards.

Cosmetic (non-medically necessary) orthodontia

DefinitionOrthodontic care performed primarily to improve cosmetic appearance or to treat mild to moderate malocclusion that is not considered medically or dentally necessary under plan guidelines.

Clinical scopeMay address misaligned or crowded teeth, crossbites, prognathic or retrognathic jaw appearance due to tooth position, and control of harmful habits.

Treatment goalAchieve improved function and/or cosmetic appearance consistent with overall health, potentially reducing risk of tooth decay, gingival/periodontal disease, tooth loss, and TMJ/TMD problems.

Coverage noteCosmetic orthodontia is explicitly stated as not medically or dentally necessary; coverage depends on the member's group contract.

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
D8O80	Comprehensive treatment of the adolescent dentition
D8090	Comprehensive treatment of the adult dentition
D8660	Pre-orthodontic treatment examination to monitor growth and development
D8670	Periodic orthodontic treatment visit
D8680	Orthodontic retention

OpenPayer

Orthodontia — Non‑Medically Necessary (Cosmetic) Orthodontia Care

Coverage Criteria for Orthodontic Services

Coding and Procedure Codes (Informational)

Provider Responsibilities and Documentation

Definitions and Standards

Background