CurrentBlue Cross Blue Shield - MainePolicy 08-002

Non Medically Necessary Orthodontia Care (2024 Policy) PDF. Opens in a new window

Policy provides guidance on evaluation and coverage considerations for non-medically necessary (cosmetic) orthodontic services, including definitions, qualifying guidelines, required provider supervision, included standard benefit components, and informational CDT codes. Coverage ultimately depends on group contract terms and state/federal mandates.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyNon Medically Necessary Orthodontia Care (2024 Policy) PDF. Opens in a new window

Policy CodePolicy 08-002

Change TypeRevised

Effective DateJan 1, 2024

Next Review Date

Key ActionEnsure diagnosis, treatment planning, and hands-on treatment are performed under the direct supervision of an actively licensed dentist or orthodontist to qualify for benefits.

SourceLink

POLICY UPDATE CHANGES

Policy status indicated as Revised with last review date 11/01/2023 and publish date 01/01/2024.

3Types of Orthodontic Coverage Classified

11CDT Codes Listed (informational)

1Policy Guideline Number

Coverage Summary

This policy (Guideline # 08-002) provides guidance on evaluation and coverage considerations for non-medically necessary (cosmetic) orthodontic services, including definitions, qualifying guidelines, required provider supervision, included standard benefit components, and informational CDT codes. Effective date: 01/01/2024. Last review date: 11/01/2023. Coverage determinations for the services described depend on the member's group contract terms and any applicable state or federal mandates; inclusion of a service in this policy or a medical necessity determination does not guarantee that the service is a covered benefit payable by the dental plan.

Medical Necessity Criteria

General Coverage Principles

Coverage determination for non-medically necessary orthodontia is contract-dependent and must meet generally accepted standards of dental care.

ALL of the following

Services must be provided by a licensed dentist or orthodontist exercising prudent clinical judgment
Services must be for the purpose of preventing, evaluating, diagnosing or treating orthodontic problems
Coverage is determined by group contract and may be limited by plan contract requirements
All necessary dental procedures that may affect orthodontic treatment must be completed prior to initiation of orthodontic therapy

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Classification of Orthodontia Coverage

There are three specific types of orthodontic coverage.

ANY of the following

State mandated treatment for medically necessary orthodontia
Orthodontia considered medically necessary according to plan guidelines
Cosmetic (non-medically necessary) orthodontia

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Non-Medically Necessary (Cosmetic) Orthodontia Criteria

Cosmetic orthodontia is generally not medically/dentally necessary but may be appropriate for mild to moderate malocclusion.

ALL of the following

Orthodontia that is primarily cosmetic in nature is considered non-medically necessary
Cosmetic orthodontia may be used to treat mild to moderate malocclusion and minor dysfunctional occlusal discrepancies
The goal of treatment is improved function and/or cosmetic appearance consistent with supporting overall health status and decreasing risk of dental disease and/or TMJ/TMD problems

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Provider Supervision and Service Components

Requirements to qualify for benefits and standard included services.

ALL of the following

Diagnosis, treatment planning, and hands-on treatment of non-medically necessary orthodontia must be performed under the direct supervision of an actively licensed dentist or orthodontist
Standard benefits may include pre-orthodontic treatment visit, examination, start-up records, limited or comprehensive orthodontic treatment, periodic orthodontic treatment visit, orthodontic retention, and post-treatment records
All necessary dental procedures that may affect orthodontic treatment must be completed prior to initiation of orthodontic therapy

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Informational CDT Codes

Informational CDT Codes Listedmixed

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
D8660	Pre-orthodontic treatment examination to monitor growth and development
D8670	Periodic orthodontic treatment visit
D8680	Orthodontic retention

1–10 of 11

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Provider Actions & Requirements

Documentation Required

Direct Supervision Required

Ensure diagnosis, treatment planning, and hands-on treatment are performed under the direct supervision of an actively licensed dentist or orthodontist to qualify for benefits.

Documentation Required

Pre-treatment Completion

Complete all necessary dental procedures that may affect orthodontic treatment prior to initiation of orthodontic therapy.

Billing Rule

Verify Member Contract Benefits

Check the member's group contract and plan benefits to determine if non-medically necessary orthodontia services are covered for the individual member; inclusion of codes in this policy is informational only and does not guarantee coverage or reimbursement.

D8010
D8020
D8030
D8040
D8070
D8080
D8090
D8660
D8670
D8680
D8681

Background & Definitions

Scope: This policy addresses cosmetic (non-medically necessary) orthodontia and instructs dental reviewers to interpret services against generally accepted standards of dental care when determining necessity. Reviews are performed because plan contract(s) may require that benefits meet specific contract requirements and recognized standards of care. Coverage is contract-dependent and may be limited or excluded by the member's plan; a determination that care is medically or dentally necessary does not constitute a warranty that the service is a covered benefit payable by the dental plan.

Role of reviewers and provider requirements: Diagnosis, treatment planning, and hands-on treatment must be performed under the direct supervision of an actively licensed dentist or orthodontist for benefits to qualify. Standard benefit components listed as informational include pre-orthodontic treatment visit, examination, start-up records, limited or comprehensive orthodontic treatment, periodic orthodontic visits, orthodontic retention, and post-treatment records. All necessary dental procedures that may affect orthodontic treatment must be completed prior to initiation of orthodontic therapy.

Coding and contract note: Informational CDT codes are provided (e.g., D8010–D8090, D8660, D8670, D8680, D8681) for reference only; inclusion of codes does not guarantee coverage or reimbursement — providers and reviewers must check the member's group contract and plan benefits to determine coverage for non-medically necessary orthodontia for an individual member.

Definitions

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyNon Medically Necessary Orthodontia Care (2024 Policy) PDF. Opens in a new window

Policy CodePolicy 08-002

Change TypeRevised

Effective DateJan 1, 2024

Next Review Date

Key ActionEnsure diagnosis, treatment planning, and hands-on treatment are performed under the direct supervision of an actively licensed dentist or orthodontist to qualify for benefits.

SourceLink

On This Page

OpenPayer

Non Medically Necessary Orthodontia Care (2024 Policy) PDF. Opens in a new window

Coverage Summary

Medical Necessity Criteria

Informational CDT Codes

Provider Actions & Requirements

Background & Definitions

Revision History