CurrentBlue Cross Blue Shield - MainePolicy 08-001

Orthodontia - Medically Necessary Orthodontia Care

Defines criteria and documentation requirements for review and preauthorization of medically necessary orthodontic treatment for members whose contracts permit medical/dental necessity review; distinguishes medically necessary from cosmetic orthodontia.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyOrthodontia - Medically Necessary Orthodontia Care

Policy CodePolicy 08-001

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review Date

Key ActionObtain preauthorization with completed HLD scoring and required radiographs/photos and treatment plan before initiating MNOC.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

HLD ≥ 26HLD threshold

10 documentsRequired items

CDT listCDT list

RequiredPreauthorization

Coverage Criteria

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Provider and purpose: Orthodontia services must be provided by a licensed dentist or orthodontist and be intended to prevent, evaluate, diagnose or treat a dental injury or disease (not primarily cosmetic).

Severity and diagnosis: Patient must have a severe handicapping malocclusion that severely interferes with function (mastication, speech, or ability to maintain oral hygiene) or be associated with a documented craniofacial deformity or severe dento‑facial trauma; documented craniofacial deformities that create a handicapping malocclusion automatically qualify.HLD >= 26 unless state/group threshold differs

Examples include cleft palate, severe open bite, severe Class II with palatal impingement, severe Class III, Treacher Collins Syndrome.

Dental development: Patient must present with fully erupted permanent teeth; if teeth are partially erupted or impacted due to severe crowding, at least three‑quarters (¾) of the clinical crown must be exposed.

Index scoring and preauthorization: Medically necessary orthodontic care requires preauthorization and validation using a recognized index (HLD Index). The subscriber must achieve a minimum HLD score of 26 unless a different threshold is set by the state or group.HLD >= 26 unless state/group threshold differs

Preauthorization is required prior to initiation of services.

Documentation for preauthorization: Preauthorization submission must include the completed HLD scoring index, orthodontic treatment plan, narrative describing the severe handicapping malocclusion, required radiographs and photographs, study model images or CAD/CAM equivalent, and when surgery is planned, the surgical treatment plan and letter of medical necessity.

See documentation module for full list of 10 required items.

Cosmetic orthodontia care and minor corrections of malocclusion that are not dysfunctional are not considered medically or dentally necessary. The plan distinguishes these services from medically necessary treatment because their primary purpose is aesthetic improvement rather than prevention, diagnosis, or treatment of a dental injury or disease.

Orthodontic services provided solely to correct malocclusion that is not dysfunctional (that is, malocclusion that does not severely interfere with mastication, speech, or oral hygiene) are not medically necessary. Handicapping esthetic diagnoses are not used as the basis for medical necessity determinations, and minor corrections intended primarily for cosmetic benefit are excluded from coverage.

Coding — Procedure and Index

Included CDT 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.
D8660	Pre-orthodontic treatment examination to monitor growth and development.
D8670	Periodic orthodontic treatment visit.
D8693	Re-cement or re-bond fixed retainer.

1–10 of 12

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HLD (Handicapping Labio‑Lingual Deviation) Index — threshold

HLD minimum scoreMinimum Handicapping Labio‑Lingual Deviation (HLD) Index score of 26 points required (or the threshold set by the member's state/group).

PurposeHLD Index is a validated, recognized index used to determine dental/medical necessity for MNOC.

Applies whenUsed when patient presents with severe handicapping malocclusion and when member contract and state/group thresholds permit review.

Documentation linkageCompleted HLD scoring index must be submitted as part of preauthorization documentation.

Provider Actions and Requirements

Prior Authorization

Preauthorization and HLD scoring required

Medically necessary orthodontic services require preauthorization and validation using a recognized index. The policy specifies the Handicapping Labio‑Lingual Deviation (HLD) Index with a minimum qualifying score of 26 points unless a different state/group threshold applies.

Step Therapy

Step therapy: not applicable

No step therapy requirements apply for orthodontic services under this policy.

Documentation Required

Required documentation for preauthorization

Submit the complete clinical package listed below with any preauthorization request; incomplete submissions may delay review.

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

Denial Risk

Denial risk for non‑medical or non‑covered services

Services that do not meet the plan's medical or dental necessity criteria or that are not a covered benefit per the member's contract may be denied.

Background

Medically necessary orthodontic care (MNOC) is intended to treat severe handicapping malocclusions that significantly impair function — for example, problems that interfere with proper mastication, speech, or the ability to maintain good oral hygiene. Examples include cleft palate, severe open-bite deformities, severe Class II with palatal impingement, severe Class III malocclusions, Treacher Collins syndrome, and severe dento‑facial trauma. Documented craniofacial deformities that create a handicapping malocclusion automatically qualify for MNOC. Conversely, treatments whose primary goal is cosmetic improvement or minor malocclusion corrections are not considered medically necessary.

Definitions

Handicapping malocclusion — definition and scope

DefinitionA malocclusion that severely interferes with function (proper mastication, speech, ability to maintain good oral hygiene), often including crooked, crowded, or protruding teeth and conditions such as cleft palate, severe open bite, severe Class II with palatal impingement, severe Class III, Treacher Collins Syndrome, or severe dento‑facial trauma.

Functional impactSeverely interferes with mastication, speech, or ability to maintain adequate oral hygiene; may require combined pre‑surgical orthodontics and surgery.

Automatic qualifiersDocumented craniofacial deformities that create a handicapping malocclusion automatically qualify for MNOC.

ExclusionsHandicapping esthetic diagnoses alone are not considered part of the determination; cosmetic orthodontia is not medically necessary.

Medically Necessary Orthodontia Care (MNOC) — definition

DefinitionOrthodontic treatment indicated when failure to provide services would result in deleterious effects to overall health or is necessary to sustain life; not primarily cosmetic and effective for treating dental injury or disease.

Provider requirementMust be provided by a licensed dentist or orthodontist and performed according to generally accepted standards of dental practice.

PreauthorizationMNOC services require preauthorization prior to initiation of any services.

Clinical indicationsIndicated for severe malocclusions, dysfunctional occlusions, or as pre‑surgical preparation for craniofacial correction.