Description
Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions. The intent of orthodontic treatment is the satisfactory correction of a severe functional impairment to create a healthy bite. Abnormal bites can lead to multiple oral health problems including: tooth decay, gum disease, speech and chewing disturbances, enamel issues and ultimately can contribute to tooth loss.

Abnormal bites are generally noticed between the ages of 6 – 12, and treatment often begins between the ages of 8 – 14.

Policy
This health plan will provide coverage for orthodontic services (braces) when they are determined to be medically necessary because the medical criteria and guidelines shown below are met.

Benefit Application
This coverage policy relates only to the services or supplies described herein. Please refer to the member’s benefit booklet for availability of benefits. Members' benefits may vary according to benefit design. Member benefit language should be reviewed before applying the terms of this coverage policy.

Policy Guidelines
When orthodontic services (braces) are covered, under all four criteria:

1. Current enrollment in a Blue Cross and/or Blue Shield medical plan that provides coverage for orthodontic services (braces)
2. Age 18 years or under at initial request for program services (eligibility determination and approval for program services must occur before the last day of the month of 18th birthday)
3. There is severe malocclusion that results in functional impairment resulting from abnormal relationship between upper and lower jaw as measured by a Salzmann Scale score at or above 35 (approved screening tool) and documented by photographs and X-rays
4. The severe malocclusion is caused by craniofacial abnormalities like cleft lip and palate or other conditions caused by a syndrome

Contract verbiage will be utilized in determining benefit. Not all contract have orthodontic benefits as medical benefits.

Orthodontic services are considered to be definitive treatment of transitional, adolescent or adult (up to 19 years) dentition to correct function impairment resulting from severe malocclusion. This treatment usually includes use of fixed appliances (braces) on adult teeth.

Oral and maxillofacial procedures and orthognathic surgery services are excluded from coverage by plan document.

Appendix
Salzmann Scale:
https://www.dominiondental.com/files/Dentist_Forms/Other_Forms/salzmann_evaluation_index.pdf

Definitions

Appliances: Any device, attached to the teeth or removable, designed to move the teeth,change the position of the jaw or hold the teeth in their finished positions after braces are removed. 

Archwire: The metal wire that is attached to the brackets and used to move the teeth.

Band: The metal ring that is cemented to a tooth for strength and anchorage.

Braces: A word commonly used to describe a fixed orthodontic appliance, usually composed of brackets, bands and wires.

Bruxism: Grinding the teeth, usually during sleeping. Bruxism can cause abnormal tooth wear and may lead to pain in the jaw joints.

Buccal: The cheek side of the back teeth in both arches or jaws.

Buccal Tube: A small metal part of the bracket welded to the cheek side of the molar band. The tube may hold an archwire, lip bumper, headgear facebow or other appliances an orthodontist may use to move the teeth. 

Cephalometric Radiograph: A lateral (side view) X-ray of the head.

Chain: A stretchable series of elastic o-rings connected together and placed around each bracket to hold the archwire in place and move the teeth.

Class I Malocclusion: A malocclusion with the proper molar relationship and teeth that are crowded together, spaced apart, an overbite, an openbite, a posterior crossbite or an anterior crossbite. 

Class II Malocclusion: A malocclusion with the upper front teeth protruding or due to the lower teeth and/or jaw positioned back relative to the upper teeth and/or jaw.

Class III Malocclusion: A malocclusion with the lower front teeth protruding or due to the lower teeth and/or jaw positioned ahead relative to the upper teeth and/or jaw. 

Closed Bite/Deep Bite: Also known as deep overbite, this occurs when the upper front teeth overlap the bottom front teeth an excessive amount.

Comprehensive Treatment: Complete orthodontic treatment performed to correct a malocclusion.

Congenitally Missing Teeth: A genetic occurrence in which the expected number of permanent teeth do not develop.

Crossbite: Upper posterior (back) teeth are in crossbite if they erupt and function inside or outside of the arch in the lower posterior teeth. Lower anterior (front) teeth are in crossbite if they erupt and function in front of the upper anterior teeth. A crossbite can be individual teeth or groups of teeth.

Diagnostic Records: The material and information that the orthodontist needs to properly diagnose and plan a patient's treatment. Diagnostic records may include a thorough patient health history, a visual examination of the teeth and supporting structures, plaster models of the teeth, a wax bite registration, extraoral and intraoral photographs, a panoramic and a cephalometric radiograph.

Ectopic Eruption: Term used to describe a tooth or teeth that erupt in an abnormal position.

Extraction: The removal of a tooth.

Elastics: Rubber bands. During certain stages of treatment, small elastics or rubber bands are worn to provide individual tooth movement or jaw alignment.

Facebow: A wire appliance used with a nightbrace or headgear. Primarily used to move the upper first molars back, creating room for crowded or protrusive front teeth. The facebow has an internal wire bow and an external wire bow. The internal bow attaches to the buccal tube on the upper molar bands inside the mouth and the outer bow attaches to the breakaway safety strap of the nightbrace.

Fiberotomy: A surgical procedure designed to sever fibers of attachment around the tooth, usually performed to reduce the potential for relapse or post-orthodontic treatment tooth movement.

Fixed Appliances: An orthodontic appliance that is bonded or cemented to the teeth and cannot be or should not be removed by the patient.

Functional Appliances: Appliances that utilize the muscle action produced when speaking, eating and swallowing to produce force to move the teeth and align the jaws. They are also known as orthopedic appliances with names such as orthopedic corrector, activator, bionator, Frankel, Herbst or twin block appliances.

Gummy Smile: Showing an excessive amount of gingival (gum) tissue above the front teeth when smiling.

Headgear: An appliance worn outside the mouth to provide traction for growth modification and tooth movement.

Herbst Appliance: This appliance is used to move the lower jaw forward. It can be fixed or removable. When it is fixed, it is cemented to teeth in one or both arches using stainless steel crowns. An expansion screw may be used simultaneously to widen the upper jaw.

Impaction: A tooth that does not erupt into the mouth or only erupts partially is considered impacted.

Interceptive Treatment: Orthodontic treatment performed to intercept a developing problem. Usually performed on younger patients who have a mixture of primary (baby) teeth and permanent teeth.

Interproximal Reduction: Removal of a small amount of enamel from between the teeth to reduce their width. Also known as reproximation, slenderizing, stripping, enamel reduction or selective reduction. 

Labial: The surface of the teeth in both arches that faces the lips.

Ligating Modules: A small elastic o-ring, shaped like a doughnut, used to hold the archwire in the bracket.

Lingual: The tongue side of the teeth in both arches.

Lip Bumper: A wire appliance used to move the lower molars back and the lower front teeth forward, creating room for crowded front teeth. The lip bumper is an internal wire bow that attaches to the buccal tubes on the cheek side of the lower molar bands inside the mouth. The front portion of the bow has an acrylic pad or bumper that rests against the inside of the lower lip. The lower lip muscles apply pressure to the bumper, creating a force that moves the molars back.

Lip Incompetence: The inability to close the lips together at rest, usually due to protrusive front teeth or excessively long faces.

Malocclusion: The term used in orthodontics to describe teeth that do not fit together properly. From Latin, the term means "bad bite."

Mixed Dentition: The dental developmental stage in children (approximately ages 6-12) when they have a mix of primary (baby) and permanent teeth.

Mouthguard: A removable device used to protect the teeth and mouth from injury caused by sporting activities. The use of a mouthguard is especially important for orthodontic patients.

Nightguard: A removable appliance worn at night to help an individual minimize the damage or wear while clenching or grinding teeth during sleep.

Open Bite: A malocclusion in which teeth do not make contact with each other. With an anterior open bite, the front teeth do not touch when the back teeth are closed together. With a posterior open bite, the back teeth do not touch when the front teeth are closed together.

Orthodontics: The specialty area of dentistry concerned with the diagnosis, supervision, guidance and correction of malocclusions. The formal name of the specialty is orthodontics and dentofacial orthopedics.

Orthodontist: A specialist in the diagnosis, prevention and treatment of dental and facial irregularities. Orthodontists are required to complete college requirements, graduate from an accredited dental school and successfully complete a minimum of two academic years of full-time, university-based study at an accredited orthodontic residency program. Only those who have completed this education may call themselves "orthodontists." Orthodontists limit their practice to orthodontic treatment only unless they have training in another dental specialty. Only residency-certified orthodontists may be members of the American Association of Orthodontists.

Orthopedic Appliance: A removable functional appliance designed to guide the growth of the jaws and face.

Panoramic Radiograph: An X-ray that shows all the teeth and both jaws on one film.

Palatal Expander: A fixed or removable device used to make the upper jaw wider.

Periodontal: Refers to the hard and soft tissue, or supporting structures, around the teeth.

Preventive Treatment: Orthodontic treatment to prevent or reduce the severity of a developing malocclusion (bad bite).

Removable Appliance: An orthodontic appliance that can be removed from the mouth by the patient. Removable appliances are used to move teeth, align jaws and to keep teeth in their new positions when the braces are removed (retainers).

Retainer: A fixed or removable appliance worn after the braces are removed. A removable retainer attaches to your upper and/or lower teeth and holds them in their finished positions.

Rubber Bands: During certain stages of treatment, small elastics or rubber bands are worn to provide individual tooth movement or jaw alignment.

Safety Strap: The safety strap prevents the facebow of the headgear from coming loose and causing injury.

Separators: An elastic o-ring or small wire loop placed between the teeth to create space for placement of bands. Separators are usually placed between the teeth a week before bands are scheduled to be cemented to the teeth.

Serial Extraction: Selective or guided removal of certain primary (baby) teeth and/or permanent teeth over a period of time to create room for permanent teeth.

Space Maintainer: A fixed appliance used to hold space for an unerupted permanent tooth after a primary (baby) tooth has been lost prematurely, due to accident or decay.

Supernumerary Teeth: A genetic occurrence in which there are more teeth than the usual number. These teeth can be malformed or erupt abnormally.

Tongue Crib: A fixed appliance used to help a patient stop habits or undesirable tongue forces exerted on the teeth and bone that supports the teeth.

Tongue Thrust: An individual's tongue pushes against the teeth when swallowing. Forces generated by the tongue can move the teeth and bone and may lead to an anterior or posterior open bite.

Wires: Also known as archwires, they are held in the brackets using small elastic o-rings or stainless steel wire ligatures. Wires are used to move the teeth.

1. Rajvikram, N. , Saravanan, P., Vanathi, K. , Shanmugam, T., Syndromic Malocclusions.  Virtual Journal of Orthodontics; September 9, 2011.  Available online at: http://www.vjo.it

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines

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