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  2. Medical billing in dentistry

Medical coverage for pediatric orthodontics

Orthodontic coverage for medical necessary treatment

Under the Affordable Care Act, there is coverage under medical plans for pediatric (19 and under) orthodontics for some diagnoses. Many policies indicate coverage for ortho for diagnoses/conditions such as severe malocclusions, speech abnormalities, trauma, etc.

Here’s a link to a good guide from United Healthcare on the Pediatric Dental Essential Health Benefit in the Affordable Care Act (ACA), which includes “medically necessary orthodontia” (among other things, of course)

https://www2.cbia.com/ieb/ag/medical/zpdf/MemberBenefits/Oxford%20Pediatric%20Dental.pdf

And these below are really good reads to wrap your head around it as well – a few sample medical policies on ortho coverage for pediatrics under the medical policy…..they outline the conditions/criteria the patient has to have in order for the ortho to be covered by the medical policy:

BCBS of North Carolina - Orthodontics for Pediatric Patients

https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/orthodontics_for_pediatric_patients.pdf

Aetna - Medically Necessary Orthodontia Related to the Pediatric Dental Essential Benefit in the Affordable Care Act (ACA)

https://www.aetna.com/health-care-professionals/clinical-policy-bulletins/dental-clinical-policy-bulletins/DCPB039.html#

BCBS of Rhode Island - Pediatric Dental Services -Essential Health Benefit https://www.bcbsri.com/sites/default/files/polices/Pediatric_%20Dental_%20Services%20_Essential_%20Health_%20Benefit_3.pdf

The one for Aetna even lists out the codes you might use! Here they are below:

Possible orthodontic codes1*

  • D8010- Limited orthodontic treatment of the primary dentition
  • D8020- Limited orthodontic treatment of the transitional dentition
  • D8030- Limited orthodontic treatment of the adolescent dentition
  • D8040- Limited orthodontic treatment of the adult dentition
  • D8050- Interceptive orthodontic treatment of the primary dentition
  • D8060- Interceptive orthodontic treatment of transitional dentition
  • D8070- Comprehensive orthodontic treatment of the transitional dentition
  • D8080- Comprehensive orthodontic treatment of the adolescent dentition
  • D8090- Comprehensive orthodontic treatment of the adult dentition