CurrentEmpire BluecrossPolicy 08-001

Medically Necessary Orthodontia Care

Defines clinical criteria, required documentation, and coding guidance for determinations of medically necessary orthodontic treatment for Empire Bluecross members; applies to dental providers seeking preauthorization for orthodontic services under contracts that permit medical necessity review.

Policy Summary

PayerEmpire Bluecross

PolicyMedically Necessary Orthodontia Care

Policy CodePolicy 08-001

Change TypeNo material change

Effective Date01/01/2022

Next Review Date

Key ActionObtain preauthorization and submit required documentation including completed HLD score, treatment plan, radiographs, photographs, and study model images before initiating medically necessary orthodontic services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥26HLD threshold

RequiredPrior auth

ListedAutomatic qualifiers

CDT 2022Coding ref

Coverage Criteria — Medically Necessary Orthodontia

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Medically Necessary Orthodontia Criteria

Covered when ALL of the following are met

Severity: Patient presents with a severe handicapping malocclusion that severely interferes with function (mastication, speech, oral hygiene) or has a documented craniofacial deformity that creates a handicapping malocclusion (these documented craniofacial deformities are automatic qualifiers).

examples include cleft palate, severe open bites, deep destructive bites with palatal impingement, severe Class II/III malocclusions, Treacher Collins syndrome, severe dento-facial trauma

Dentition stage: Patient must present with fully erupted permanent teeth; if partially erupted or impacted due to severe crowding, the tooth must show exposure of at least a portion of the clinical crown as specified by the treatment plan.

from criteria

Validated index: Patient must achieve a Handicapping Labio-Lingual Deviation (HLD) Index minimum score of 26 points (or the threshold set by the state/group) to qualify for medically necessary orthodontia.HLD >= 26

Handicapping esthetic diagnoses are not part of the determination

Preauthorization and documentation: Preauthorization is required prior to initiation; submit completed HLD scoring index, orthodontic treatment plan, panoramic and/or mounted full‑mouth radiographs, narrative describing the severe handicapping malocclusion, cephalometric x‑ray with tracing, intra‑oral photographs (right, left occlusal, anterior), facial frontal and profile photographs, maxillary and mandibular occlusal photographs, photographs of articulated study models or ortho CAD/CAM equivalent (all views), and when surgery is planned include the surgical treatment plan and letter of medical necessity.

see documentation list

Coding References and Indices

Relevant CDT Codes (informational)CDT

D8660	Pre-orthodontic treatment examination to monitor growth and development.
D8030	Limited orthodontic treatment of the adolescent dentition.
D8040	Limited orthodontic treatment of the adult dentition.
D8080	Comprehensive treatment of the adolescent dentition.
D8090	Comprehensive treatment of the adult dentition.
D8670	Periodic orthodontic treatment visit.
D8693	Re-cement or re-bond fixed retainer.
D7280	Surgical access of an unerupted tooth.
D7283	Placement of device to facilitate eruption of impacted tooth.

Diagnosis codes (referenced)ICD-10

ICD-10-CM

Diagnoses for dental diseases and conditions; see current CDT code book for details.

Handicapping Labio-Lingual Deviation (HLD) Index — Threshold

HLD Index thresholdMinimum Handicapping Labio-Lingual Deviation (HLD) Index score required to qualify: HLD ≥ 26 points (or the threshold set by the state/group)

Validation requirementQualified cases must meet a validated, recognized index (HLD) to determine medical necessity

Preauthorization linkageHLD score must be included with required preauthorization documentation (Completed HLD Scoring Index)

Exclusion noteHandicapping esthetic diagnoses are not part of the HLD determination

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Medically necessary orthodontic services require prior authorization before initiation of treatment. A determination that services are medically necessary applies only where the contract permits medical necessity review and does not guarantee benefit coverage or payment.

Services determined medically necessary require prior authorization.
Medically necessary determination does not guarantee coverage; applies only where contract permits review and member eligibility applies.

Note

Provider Actions

Providers must submit required documentation to support preauthorization requests. Include an action-oriented checklist to facilitate timely review and reduce risk of denial.

Obtain preauthorization before initiating any orthodontic services.
Ensure documentation is complete and legible to prevent processing delays or denials.

Documentation Required

Required Preauthorization Documentation

The following documentation is required with preauthorization requests to establish medical necessity. Use validated indices and provide all listed materials; incomplete submissions may be denied.

Completed HLD (Handicapping Labio-Lingual Deviation) Scoring Index (minimum score 26 or the threshold set by the state/group).
Orthodontic treatment plan.
Panoramic and/or mounted full-mouth radiographic images.
Cephalometric X-ray with teeth in centric occlusion and cephalometric tracing when indicated.
Narrative describing the nature of the severe physically handicapping malocclusion.
Intra-oral photographs depicting right and left occlusal relationships and an anterior view.
Facial photographs (frontal and profile views).
Maxillary and mandibular occlusal photographs.
Photographs of articulated study models or ortho CAD/CAM electronic equivalents including lateral, anterior, and posterior views.
When surgery is treatment planned, include the surgical treatment plan and a letter of medical necessity.

Denial Risk

Provider Notice

A determination that services are medically necessary is limited to contracts that permit medical necessity review and is subject to member eligibility and plan benefit terms; it is not a guarantee of payment.

Medically necessary determination does not guarantee that the service is a covered benefit payable by the plan.
Coverage determination applies only where the member's contract allows medical/dental necessity review and the member is eligible at the time of service.

Key Definitions

Handicapping malocclusion — Definition and examples

Definition — Handicapping malocclusionA malocclusion that severely interferes with function (mastication, speech, oral hygiene) and typically requires combined orthodontic and surgical treatment; examples include cleft palate, severe lateral or anterior open bite deformities, deep destructive bites with palatal impingement, severe class III malocclusions (severe underbite), Treacher Collins syndrome, and severe dento-facial trauma.

Automatic qualifiersDocumented craniofacial deformities that create a handicapping malocclusion are automatic qualifiers for MNOC (e.g., cleft palate).

Functional impact examplesIncludes conditions causing impaired mastication, speech, or inability to maintain oral hygiene (crooked, crowded, or protruding teeth affecting function).

Standards source summaryGenerally accepted standards of dental practice are based on peer-reviewed dental literature, views of recognized dentists, specialty society recommendations, and other credible sources.

Generally accepted standards of dental practice

Definition — Generally accepted standardsStandards based on credible scientific evidence published in peer‑reviewed dental literature; views of recognized dentists in the relevant clinical area; specialty society recommendations; and other relevant factors from credible sources.

PurposeUsed to define accepted dental care for evaluating, diagnosing, or treating dental injury or disease in accordance with prudent clinical judgment.

ApplicationStandards guide decisions on type, frequency, and extent of dental services and help distinguish medically necessary from cosmetic care.

Background — MNOC Intent

Medically Necessary Orthodontia Care (MNOC) is intended for severe, handicapping malocclusions where failure to treat would adversely affect function or overall health. MNOC typically involves pre‑surgical orthodontics combined with surgical correction and is performed by a licensed dentist or orthodontist. Examples of conditions that commonly qualify include cleft palate, severe open bites, deep destructive bites with palatal impingement, severe class III malocclusions, Treacher Collins syndrome, and severe dento‑facial trauma. Documented craniofacial deformities that create a handicapping malocclusion are considered automatic qualifiers for MNOC.