Your insurance may pay for medically necessary orthodontic braces.

However, the definition is fuzzier than a Georgia peach and includes many standards, making it hard to know if the company will approve or deny your claim.

For instance, your private health insurance has one benchmark based on a connection to a covered accident or illness. Meanwhile, dental plans with orthodontic coverage require a severe handicapping malocclusion – without a linkage to a medical problem.

Finally, Medicaid can employ either set of criteria because of its hybrid design. Then, each state adds a wrinkle.  

Fortunately, you can find a breakdown below.

Private Insurance: Medically Necessary Braces

There are two main definitions of medically necessary orthodontic treatment, depending on the private insurance type in question. Plus, each company evaluating claims for approval or denial adopts slightly different standards within each category.

Both dental and health insurance have different rules, and you are not guaranteed coverage for braces they classify as cosmetic.

Dental Insurance

Your dental insurance will adhere to a more lenient standard of medical necessity – provided it includes orthodontia benefits – as many do not.  Plans designed to cover braces may approve your claims after the provider submits evidence of a severe handicapping malocclusion.

  • Plastic study models of teeth
  • Cephalogram: X-rays of the jaw
  • Panoramic radiograph of the mouth
  • Intraoral photographs

Each dental insurance company sets the objective measures for determining whether a covered member meets the standard for a handicapping malocclusion. For instance, one carrier combines a point system with automatic qualifying reasons.[1]

  • Point systems measure the degree of malocclusion with higher numbers equating to greater severity of misalignment: Handicapping Labio-Lingual Deviation (HLD) Index above 28
  • Automatic qualifying reasons can make a patient eligible if a single defect meets or exceeds a standard[2]
    • Overjet equal to or greater than 9 mm
    • Reverse over-jet equal to or greater than 3.5 mm
    • Mandibular protrusion greater than 3.5 mm
    • Severe maxillary anterior crowding, greater than 8 mm
    • Lateral or anterior open-bite equal to or greater than 4 mm
    • Posterior cross-bite with no functional occlusal contact
    • Impinging over-bite with one of two qualifiers
      • Palatal trauma
      • Mandibular anterior gingival trauma
    • One or more impacted teeth with an eruption
    • Defects of cleft lip and palate
    • Craniofacial anomalies or trauma
    • Congenitally missing teeth

Health Insurance

Your health insurance might pay for medically necessary orthodontic braces for both children and adults. Since far more families maintain this type of coverage, it makes sense to explore the standards under which your plan might evaluate a claim.

However, your health insurance will adjudicate claims under a definition that is exceptionally narrow: a procedure that prevents, diagnoses, or treats an injury, disease, or symptoms.

Accidents

Your health insurance may deem dental braces as medically necessary after a non-biting accidental injury such as a broken jaw. For example, an orthodontist may need to provide treatment to reposition your teeth into the correct alignment.

In this case, the alignment procedure is incident to and an integral part of a covered service: the medical care needed to restore proper chewing function after the accidental injury.

Illnesses

Your health insurance may also approve claims deemed medically necessary because the dental braces treat a covered illness. However, the list of qualifying conditions is often different for children and adults.

Children

Medical insurance may cover necessary orthodontic work that corrects congenital deformities that result in physically handicapping malocclusions in children under the age of 18 or 19.[3]

  • Cleft Lip and or Cleft Palate
  • Crouzon Syndrome/Craniofacial Dysostosis
  • Hemifacial Hypertrophy/Congenital Hemifacial Hyperplasia
  • Parry-Romberg Syndrome/Progressive Hemifacial Atrophy
  • Pierre-Robin Sequence/Complex
  • Treacher-Collins Syndrome/Mandibulofacial Dysostosis
Adults

Medical insurance may deem orthodontic treatment necessary for adults (21 +) dealing with specific illnesses and diseases. However, it could prove more challenging to approve installation than removals.

  • Installation of braces for adults might fit into the approval category if not more costly than alternative treatments for covered illnesses.
    • Temporomandibular Joint Disorders (TMJ or TMD) requiring bite adjustments
    • Sleep apnea when crooked teeth restrict or block airflow
  • Removal of braces for adults frequently meets the approval criteria for treating a covered disease affecting the head, neck, and jaw, such as cancer and osteoporosis.
    • Before radiation therapy
    • Before highly stomatotic chemotherapy
    • Complications of IV bisphosphonates

Medicaid: Medically Necessary Orthodontia

Medicaid is a joint federal and state-run insurance program for low-income families. The Medicaid definition for medically necessary orthodontia is all over the map because it operates like two coverage types depending on circumstances.

  1. Treatment for accidental injuries and diseases apply nationwide
  2. Braces for severe handicapping malocclusions varies by region

Point Systems

Medicaid frequently uses a point system under the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT), which mandates access to orthodontic treatment for children when medically necessary.

For the states that cover handicapping occlusions in children, the objective grading protocols sometimes factor in aesthetics (appearance), while others focus on function alone. The local government agency might use one of seven possible point systems.

Include AppearanceFunction Only

Index of Complexity, Outcome, and Need

Handicapping Labio-Lingual Deviation (HLD) Index

Salzmann Index

Peer Assessment Rating Index

Dental Aesthetic Index

HLD (CalMod) Index

Index of Treatment Need

 

For example, the Salzman Index considers aesthetics by adding two points for each misaligned anterior (front) tooth and one point for posterior (back) molars.[4]

  • Intra-Arch Deviations
    • Missing
    • Crowded
    • Rotated
    • Open spacing
    • Closed spacing
  • Inter-Arch Deviations
    • Over-jet
    • Over-bite
    • Cross-bite
    • Open-bite

Healthcare

Medicaid operates as a health insurance program in all fifty states, which means that the most restrictive standard for medically necessary applies nationwide. The orthodontic braces must prevent or treat an injury, disease, or symptoms.

Therefore, both adults and children dealing with covered accidents and sicknesses affecting the jaw and neck, might have a valid claim. Have your provider submit documentation connecting the medical condition with the need for orthodontic treatment.

  • Children with congenital deformities
  • Adults addressing TMJ, sleep apnea, cancer, or osteoporosis
  • People of any age after an accidental injury affecting teeth

Final Thoughts

Determining what makes orthodontic braces medically necessary is a guessing game because each insurance company and or state government agency decide which criteria to use, and the circumstances can differ.

Health insurance companies are more likely to honor claims when the braces correct issues with your teeth linked to a covered accident or illness.

Dental plans with orthodontic coverage approve claims when the braces correct a severe handicapping malocclusion. Plus, they might employ point-scoring systems or consider whether a single defect exceeds a predefined standard.

Meanwhile, Medicaid can utilize both approaches because of their hybrid design. It provides health, dental, and orthodontic care – although benefits vary significantly by state.

Footnoted Sources:

[1] Delta Dental RI Underwriting Rules

[2] American Association of Orthodontists

[3] United Health Care Coverage Guideline

[4] Aetna Dental Salzman Index