Orthodontics - Medical Necessity Criteria

Q: When are braces and aligners medically necessary?

Generally, orthodontic appliances -- such as braces and aligners -- may be considered medically necessary when they will be used to correct a physical deformity that causes the patient to have difficulty with eating, breathing, or speaking normally. There must be documentation that the patient meets their health plan's medical necessity criteria, such as those listed below. Orthodontic treatment that is done for cosmetic reasons, or to improve patient's self-esteem, is usually not considered medically necessary.

Criteria for documenting medical necessity of orthodontics such as braces and aligners, including Invisalign.

Contents:

When are braces and aligners medically necessary?
Medical necessity criteria for orthodontics
Can Invisalign be medically necessary?
Health plan criteria for orthodontics and other references

When are braces and aligners medically necessary?

Generally, orthodontic appliances — such as braces and aligners — may be considered medically necessary when they will be used to correct a physical deformity that causes the patient to have difficulty with eating, breathing, or speaking normally. There must be documentation that the patient meets their health plan’s medical necessity criteria, such as those listed below. Orthodontic treatment that is done for cosmetic reasons, or to improve patient’s self-esteem, is usually not considered medically necessary.

Medical necessity criteria for orthodontics

The orthodontic appliance (such as braces or aligners) should be an essential part of a multidisciplinary treatment plan to correct severe handicapping malocclusion related to any of the following conditions:

Craniofacial malformations such as:
- Alveolar notch
- Amniotic band syndrome of face
- Apert’s syndrome
- Arthrogryposis
- Bird headed dwarfism
- Chondroectodermal dysplasia (Ellis-Van Crevald syndrome)
- Cleft lip
- Cleft mandible
- Cleft palate
- Cleidocranial dysplasia
- Congenital hemifacial hyperplasia / hemifacial hypertrophy
- Craniofacial dysostosis (Crouzon syndrome)
- Craniofacial microsomia
- Craniosynostosis syndromes
- Hemifacial microsomia
- Klinefelter’s syndrome
- Klippel-Fiel syndrome
- Lateral or oblique facial clefting
- Mandibulofacial dysostosis (Treacher-Collins syndrome)
- Marfan syndrome
- Oculoauriculovertebral dysplasia (Goldenhar’s Syndrome)
- Oculomandibulofacial syndrome (Hallermann Stiff syndrome, Ullrich syndrome)
- Pierre Robin syndrome
- Progressive hemifacial atrophy (Parry-Romberg syndrome)
- Short palate
- Submucous cleft
- Trisomy 21 (Down syndrome)
- Turner’s syndrome
- Velopharyngeal incompetence
Trauma involving the oral cavity
Skeletal anomaly that involves mandibular or maxillary structures

The impairment caused by the patient’s condition must be severe enough to impair their ability to eat, breathe and/or speak normally.

Related photos and x-rays must be included in the documentation.

Can Invisalign be medically necessary?

Invisalign is a set of clear plastic aligners that are similar in function to braces. As such, the medical necessity criteria for braces and other orthopedic appliances must be met; otherwise, Invisalign may be considered cosmetic. Depending on the patient’s health plan, limitations may apply even if medical necessity criteria are met. For example, the plan may state that additional costs beyond that of “standard” orthodontic appliances must be shouldered by the patient.

Health plan criteria for orthodontics and other references

Aetna Criteria for Medically Necessary Orthodontia
Alabama Medicaid Criteria for Orthodontic Services
Premera Blue Cross Criteria for Orthodontic Services for Treatment of Congenital Craniofacial Anomalies
UnitedHealthcare Dental Criteria for Medically Necessary Orthodontic Treatment