Medically Necessary Orthodontics. Orthodontic services will only be covered under this Section if the Member fits the following criteria: Members must have a fully erupted set of permanent teeth to be eligible for comprehensive orthodontic services. All orthodontic services require Authorization, a written plan of care, and must be rendered by a Provider. Orthodontic treatment must be considered medically necessary and be the only method considered capable of: Preventing irreversible damage to the member’s teeth or their supporting structures. Restoring the member’s oral structure to health and function.
Medically Necessary Orthodontics. Covered Benefits include services for limited, interceptive and comprehensive Orthodontic treatment of the primary, transitional and adolescent dentition in addition to removable and fixed appliance therapy. Treatment visits are provided for pre-orthodontic, periodic orthodontic and orthodontic retention. Members must have a fully erupted set of permanent teeth to be eligible for comprehensive orthodontic services. Orthodontic treatment must be considered medically necessary and be the only method considered capable of: Preventing irreversible damage to the member’s teeth or their supporting structures. Restoring the member’s oral structure to health and function.
Medically Necessary Orthodontics. Orthodontic services will only be covered under this Section if the Member fits the following criteria:
1. Members must have a fully erupted set of permanent teeth to be eligible for comprehensive orthodontic services.
2. All orthodontic services require Authorization, a written plan of care, and must be rendered by a Provider.
3. Orthodontic treatment must be considered medically necessary and be the only method considered capable of:
a. Preventing irreversible damage to the member’s teeth or their supporting structures.
b. Restoring the member’s oral structure to health and function.
4. A medically necessary orthodontic service is an orthodontic procedure that occurs as a part of an approved orthodontic treatment plan that is intended to treat a severe dentofacial abnormality or serious handicapping malocclusion. Orthodontic services for cosmetic purposes are not covered.
5. Orthodontia procedures will only be approved for dentofacial abnormalities that severely compromise the member’s physical health or for serious handicapping malocclusions. Presence of a serious handicapping malocclusion is determined by the magnitude of the following variables: degree of malalignment, missing teeth, angle classification, overjet and overbite, open bite, and crossbite.
6. Dentofacial abnormalities that severely compromise the member’s physical health may be manifested by:
a. Markedly protruding upper jaw and teeth, protruding lower jaw and teeth, or the protrusion of upper and lower teeth so that the lips cannot be brought together.
b. Under-developed lower jaw and receding chin.
c. Marked asymmetry of the lower face.
7. A “handicapping” malocclusion is a condition that constitutes a hazard to the maintenance of oral health and interferes with the well-being of the recipient by causing:
a. Obvious difficulty in eating because of the malocclusion, so as to require a liquid or semisoft diet, cause pain in jaw joints during eating, or extreme grimacing or excessive motions of the orofacial muscles during eating because of necessary compensation for anatomic deviations.
b. Obvious severe breathing difficulties related to the malocclusion, such as unusually long lower face with downward rotation of the mandible in which lips cannot be brought together, or chronic mouth breathing and postural abnormalities relating to breathing difficulties.
c. Lisping or other speech articulation errors that are directly related to orofacial abnormalities and cannot be corrected by means o...
Medically Necessary Orthodontics. Covered Benefits include services for limited, interceptive and comprehensive Orthodontic treatment of the primary, transitional and adolescent dentition in addition to removable and fixed appliance therapy. Treatment visits are provided for pre-orthodontic, periodic orthodontic and orthodontic retention. Orthodontic services will only be covered under this Section if the Member fits the following criteria: Members must have a fully erupted set of permanent teeth to be eligible for comprehensive orthodontic services. Orthodontic treatment must be considered medically necessary and be the only method considered capable of: Preventing irreversible damage to the member’s teeth or their supporting structures. Restoring the member’s oral structure to health and function.
Medically Necessary Orthodontics. Covered Benefits include services for limited, interceptive and comprehensive Orthodontic treatment of the primary, transitional and adolescent dentition in addition to removable and fixed appliance therapy. Treatment visits are provided for pre-orthodontic, periodic orthodontic and orthodontic retention. 97176EX-039 R01/21 20 1.
Medically Necessary Orthodontics. Covered Benefits include services for limited, interceptive and comprehensive Orthodontic treatment of the primary, transitional and adolescent dentition in addition to removable and fixed appliance therapy. Treatment visits are provided for pre-orthodontic, periodic orthodontic and orthodontic retention. Orthodontic services will only be covered under this Section if the Member fits the following criteria:
1. Members must have a fully erupted set of permanent teeth to be eligible for comprehensive orthodontic services.
2. All orthodontic services require Authorization, a written plan of care, and must be rendered by a Provider.
3. Orthodontic treatment must be considered medically necessary and be the only method considered capable of:
a. Preventing irreversible damage to the member’s teeth or their supporting structures.
