ModifiedBlue Cross Blue Shield - MainePolicy 08-001

Orthodontia - Medically Necessary Orthodontia Care

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Defines clinical criteria, documentation, coding guidance, and review requirements for determination of medically necessary orthodontic treatment under the dental plan; applies to providers and members whose contracts allow medical/dental necessity review.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyOrthodontia - Medically Necessary Orthodontia Care

Policy CodePolicy 08-001

Change TypeMinor editorial refinements

Effective Date01/01/2025

Last ReviewOct 31, 2024

Next Review DateN/A

Key ActionSubmit preauthorization with required documentation including completed HLD score and treatment plan before initiating medically necessary orthodontic services.

SourceLink

POLICY UPDATE CHANGES

Minor editorial refinements to clinical indications, criteria, and reference; intent unchanged.

26HLD threshold

10required docs

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ModifiedBlue Cross Blue Shield - MainePolicy 08-001

Orthodontia - Medically Necessary Orthodontia Care

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Maine Policy 08-001 alerts

Get alerted when Policy 08-001 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyOrthodontia - Medically Necessary Orthodontia Care

Policy CodePolicy 08-001

Change TypeMinor editorial refinements

Effective Date01/01/2025

Last ReviewOct 31, 2024

Next Review DateN/A

Key ActionSubmit preauthorization with required documentation including completed HLD score and treatment plan before initiating medically necessary orthodontic services.

SourceLink

POLICY UPDATE CHANGES

Minor editorial refinements to clinical indications, criteria, and reference; intent unchanged.

26HLD threshold

10required docs

D7280–D8693CDT examples

Coverage Criteria

Medically Necessary Orthodontia Criteria

Covered when ALL of the following are met (or an automatic qualifying condition exists):

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

Preauthorization: Medically necessary orthodontic care may require preauthorization prior to initiation of any services.

Submit required documentation and HLD scoring for review prior to treatment when preauthorization is required.

Clinical severity: The patient has a severe handicapping malocclusion (dysfunctional occlusion or underlying craniofacial abnormality) where failure to provide services would result in deleterious effects to overall health or be necessary to sustain life.

Automatic qualifying conditions include documented craniofacial deformities (e.g., cleft palate, severe class II/III, severe trauma, Treacher Collins Syndrome) per policy.

Index threshold: Subscriber must achieve a HLD (Handicapping Labio-Lingual Deviation) Index minimum score of 26 points (or the threshold set forth by each state/group) unless an automatic qualifying condition is present.HLD >= 26

Handicapping esthetic diagnoses are not part of the determination.

Impacted tooth exposure: If partially erupted or impacted teeth are present due to severe crowding, the exposed tooth must show at least three-quarters (3/4) of the clinical crown visible.>= 3/4 crown exposure

Pre-surgical planning: When orthognathic or other surgery is planned, pre-surgical orthodontics and inclusion of the surgical treatment plan and a letter of medical necessity are required for review.

Pre-surgical orthodontics may temporarily create a more dysfunctional occlusion as part of surgical preparation.

Cosmetic orthodontia services are excluded from being medically necessary. Per policy, care provided solely to improve dental appearance or to make minor corrections of malocclusion that do not impair function is not considered medically or dentally necessary.

Orthodontic services to correct malocclusion that is not dysfunctional are not considered medically necessary. Minor corrections of malocclusion and handicapping esthetic diagnoses (i.e., conditions judged primarily for cosmetic improvement rather than functional impairment) are excluded from coverage as MNOC.

Coding Guidance

CDT example procedure codesCDT

D7280	Surgical access of an unerupted tooth
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

1–10 of 13

1/2

Diagnosis codesICD-10

ICD-10-CM

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

HLD (Handicapping Labio‑Lingual Deviation) Threshold

HLD Index minimum scoreMinimum HLD (Handicapping Labio‑Lingual Deviation) Index score of 26 points required to qualify (or the threshold set by each state/group)

Automatic qualifiersAutomatic qualifying craniofacial conditions may exempt the HLD threshold (documented craniofacial deformities that create a handicapping malocclusion)

Use for medical necessity determinationValidated, recognized index criteria (HLD) are used to determine dental/medical necessity for MNOC

Handicapping estheticsHandicapping esthetic diagnoses are not considered part of the HLD determination

Provider Actions & Documentation

Prior Authorization

Prior Authorization Required

Medically necessary orthodontic care may require preauthorization prior to initiation. Submit required documentation including completed HLD Scoring Index and supporting clinical materials for review before beginning treatment to avoid claim denials or delays.

Preauthorization required when plan/contract specifies MNOC review
Include completed HLD Scoring Index
Attach full orthodontic treatment plan and narrative of handicapping condition

Note

Provider Operational Note

Providers should confirm member benefits and any contract-specific requirements prior to initiating services and follow the plan's preauthorization process. Ensure licensure of treating clinician is documented and exercise prudent clinical judgment when submitting requests.

Verify member coverage and contract-specific medical/dental necessity review provisions

Background

Medically Necessary Orthodontia Care (MNOC) is intended to treat severe, handicapping malocclusions that substantially interfere with function — for example mastication, speech, or the ability to maintain oral hygiene — and where lack of treatment would have deleterious effects on health. Typical qualifying conditions include documented craniofacial deformities or severe dento-facial trauma that commonly require a combination of pre-surgical orthodontics and surgical correction. MNOC is not intended for care that is primarily cosmetic; treatments whose goal is improvement of appearance or minor occlusal adjustments without functional impairment are excluded.

Definitions

Handicapping malocclusion — definition

DefinitionHandicapping malocclusion: a malocclusion that severely interferes with function (mastication, speech, ability to maintain good oral hygiene)

Typical featuresOften includes crooked, crowded, or protruding teeth that affect appearance, speech, and/or ability to eat

Included conditionsMay include cleft palate, severe lateral or anterior open bite deformities, severe class II with impingement of lower incisors, class III malocclusions, Treacher Collins Syndrome, and severe dento‑facial trauma

Functional impactFrequently requires combination of pre‑surgical orthodontics and surgery for correction and improved masticatory function and occlusion

Medically Necessary Orthodontia Care (MNOC) — definition and scope

Definition

Revision History

2025-01-01effective_dateLatest

Policy effective date set to 2025-01-01.

2024-10-31last_review

Committee performed minor editorial refinements to clinical indications, criteria, and references; intent unchanged.

2023-11-15annual_review

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyOrthodontia - Medically Necessary Orthodontia Care

Policy CodePolicy 08-001

Change TypeMinor editorial refinements

Effective Date01/01/2025

Last ReviewOct 31, 2024

Next Review DateN/A

Key ActionSubmit preauthorization with required documentation including completed HLD score and treatment plan before initiating medically necessary orthodontic services.

SourceLink

On This Page

Document treating provider is a licensed dentist or orthodontist

Documentation Required

Required Documentation for Clinical Review

Required documentation for clinical review must be submitted with preauthorization requests or as part of the initial claim review. Incomplete documentation may result in denial or request for additional information.

Completed HLD Scoring Index
Orthodontic Treatment Plan
Narrative describing the severe physically handicapping malocclusion
Panoramic and/or mounted full mouth radiographic images
Cephalometric radiograph with tracing; teeth in centric occlusion
Facial (frontal and profile) and intra-oral photographs (right, left, anterior, maxillary and mandibular occlusal)
Photographs of articulated study models or ortho CAD/CAM electronic equivalent (all views)
When surgery is planned: surgical treatment plan and letter of medical necessity

Denial Risk

Denial Triggers / Documentation Risks

Services that do not meet the plan's medical/dental necessity criteria or are cosmetic in nature may be denied. Handicapping esthetic diagnoses alone do not qualify. Failure to meet HLD index thresholds or to provide required documentation are common denial triggers.

Denial likely if HLD score < required threshold or no automatic qualifying condition documented
Denial likely for procedures deemed cosmetic or not meeting medically necessary criteria
Denial or delay possible if required radiographs, photographs, models, or narratives are missing

Medically Necessary Orthodontia Care (MNOC): orthodontic services where failure to provide treatment would result in deleterious effects to overall health or be necessary to sustain life; not primarily cosmetic

Scope of servicesIndicated for severe, dysfunctional malocclusions and may be pre‑surgical in nature; performed by an orthodontist and/or licensed dentist

GoalTreatment to restore or sustain function and treat dental injury or disease, not for cosmetic improvement alone

Coverage considerationBenefit coverage is based on group language and medical/dental necessity criteria; some cases are automatic qualifiers (documented craniofacial deformities)

Annual review completed by Committee.

2022-11-11annual_review

Annual review completed by Committee.

2021-10-30annual_review

Annual review completed by Committee.

2020-12-06annual_review

Annual review completed by Committee.

2020-09-09annual_revision

Annual revision recorded by Committee.

2018-01-26revision

Updates to related dental policies, HLD Index threshold, direct supervision, requirement for pre-authorization, and definitions.

2017-02-08revision

Revisions to criteria, coding, and definitions.

2015-09-21revision

Policy posting revision.

2014-03-23creation

Initial policy version created.