Kids often require orthodontic treatment, especially around the time when they attend middle and high school. Many parents are concerned to know if their insurance will cover the treatment.
Children under the age of 19 are now eligible for dental coverage under the Affordable Care Act (ACA). Although people might take for granted that orthodontic work is automatically covered, this is not always the case. For dental insurance to apply, the orthodontic treatment must be considered medically necessary.
Medical necessity would include treatment for trauma-induced malocclusions, and craniofacial abnormalities or disharmonies. These situations would be considered medically necessary for orthodontic treatment.
Also, the treatment may be covered when it is co-occurring with another medical issue such as a trauma or syndrome as when a child has a severe handicapping malocclusion that could cause harm to their emotional or physical health.
Often patients are not sure about the dental insurance coverage or benefits they have available. There is a lot of confusion surrounding medical necessity and what treatments will be covered.
Dentists can also face problems when attempting to complete and file claims on behalf of their patients under the new Affordable Care Act. It can be challenging to understand how payers define medical necessity when it relates to orthodontic treatment and what specific procedures are covered.
The American Association of Orthodontists (AAO) developed a list of auto-qualifiers that would be considered a medical necessity. These conditions include congenitally missing teeth, palate or cleft lip defects, or functional occlusal contact.
Another organization, the Pediatric Oral Health Research and Policy Center (POHRPC), is also creating a medical necessity global policy brief to define these conditions better.
For dentists, the proper documentation must be sent into the payer so that they can reimburse the charges once the condition is qualified for coverage. The dentist can do a comprehensive orthodontic assessment depending upon the payer’s requirement for medical necessity.
The dentist should include photographs and radiographs to support the patient’s need for treatment. These should be included along with the assessment. A complete evaluation will help the payer determine the medical necessity for the patient.
It should not be automatically assumed that orthodontics treatment and medical necessity will be covered by dental insurance. Because dental insurance companies naturally consider orthodontic treatment to be esthetic, it generally not included because they don’t classify it as medically necessary.
When dentists submit claims with photographs, radiographs, and a comprehensive assessment, the patient has a higher chance of having their orthodontic treatment covered by insurance.