1. My life. My smile. My orthodontist.
Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment

2. Prepared in collaboration by:
Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Prepared in collaboration by:
Handicapping Indices Task Force
Council on Orthodontic Health Care

3. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Introduction
The dental environment in which we now practice and operate has changed dramatically since the inception of the Affordable Care Act (ACA) and its subsequent benefits and mandates. As a result, orthodontics is no longer “black and white”, nor are orthodontic issues. Severe problems can occur which may fall outside usual case parameters and the experienced judgment of qualified specialists in consultation should be used to address outliers.
A case deemed to be “medically necessary”, which currently accounts for approximately 5% of cases is a very serious circumstance and should be treated on an interdisciplinary basis to vastly improve a patient’s quality of life. It is important that insurance companies as well as state and federal entities know that these cases are serious, not common, and require a special type of approval above and beyond traditional orthodontics.

4. Confusion for patients on whether or not they have coverage
Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Key Issues:
Confusion for patients on whether or not they have coverage
Confusion for members on how to navigate a new claims environment. (~10% of calls to DBAS Hotline related to MNOC)
Confusion for payers on how to quantify/qualify MNOC

5. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
This offers the AAO a unique opportunity to collaborate with outside agencies and to lead the discussion on what constitutes MNOC and how best to manage expectations of members, patients, and payers in approving and processing claims for orthodontic treatment under the MNOC definition.

6. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Confusion: Aetna Policy Statement July, 2014: To be medically necessary, "orthodontic services must be an essential part of an overall treatment plan developed by both the physician and the dentist in consultation with each other."

7. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Confusion: Delta Dental of Massachusetts: "While a child may see an orthodontist without a referral, there is no guarantee that treatment will be covered. The child's case will need to be reviewed by Delta Dental of Massachusetts for medical necessity." Also..."Medically Necessary Orthodontics means the patient must have a severe and handicapping malocclusion. This means the child's condition must be severe enough to impact their ability to function such as having trouble eating and/or speaking."

8. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Confusion: Delta Dental of Wisconsin: “Only medically necessary orthodontia services are covered requirements as part of Pediatric Oral Essential Health Benefit (POEHB). However, a waiting period can be applied. The FEDVIP benchmark plan includes a two-year wait on ortho and CMS affirmed this waiting period can be applied to medically necessary ortho.”

9. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Confusion Wellpoint: "...states may vary the language that describes medically necessary criteria and how members will qualify for medically necessary orthodontic benefits." Also, "We (Wellpoint) will request prior authorization for medically necessary orthodontia in all states. Clinical documentation will be required to support medical necessity."

10. Severe handicapping malocclusion Prior authorization
Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Confusion
Common themes:
Severe handicapping malocclusion
Prior authorization
Consultation with other healthcare providers
Submission of diagnostic records for approval
Varies from state to state

11. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
AAO Current Policies Handicapping Malocclusion 4-95 H - May 16, 1995 Readopted May 7, 2012 A handicapping malocclusion is a dentofacial abnormality which is sufficiently severe to substantially impair an individual's physical and/or emotional health.

12. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
AAO Current Policies
Medically Necessary Orthodontic Care (MNOC)
3-95 H – May 16, Readopted May Amended April 28, 2014
Medically necessary orthodontic care is defined as the treatment of a malocclusion (including craniofacial abnormalities/anomalies) that compromises the patient’s physical, emotional, or dental health. This treatment should be based on a comprehensive assessment and diagnosis done by an orthodontist, in consultation with other health care providers when indicated; and be it further
RESOLVED, that the definition of MNOC be reviewed annually by the Council on Orthodontic Healthcare and the Council on Governmental Affairs.

13. MNOC applies to a minority of cases (~5% of cases)
Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
The Handicapping Indices Task Force was established to explore the most effective and efficient methods to determine medical necessity for orthodontic treatment.
Key agreements:
MNOC applies to a minority of cases (~5% of cases)
No one index is sufficient to determine medical necessity
Collaboration with other interested parties is crucial to development of the most ideal plan
The orthodontist should be providing care in these complicated cases
Possible higher reimbursements for these cases

14. Suggested parameters: A two tiered policy structure
Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Suggested parameters:
A two tiered policy structure
1. Traditional orthodontic cases- (95% of cases)
2. Medically necessary orthodontic cases- (5% of cases)
Use of diagnostic codes (probably through ICD-10 or 11) to ease processing for payers and claims submission for members
Use of auto-qualifiers to determine medical necessity, rather than more subjective indices
Specific diagnostic records required for submission
Higher reimbursement for medically necessary cases

15. Proposed medically necessary auto-qualifiers………
Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Proposed medically necessary auto-qualifiers………
Medically Necessary Orthodontics should be deemed necessary and qualified when it is part of a case involving treatment of cranio-facial anomalies, malocclusion caused as the result of trauma, or a severe malocclusion or cranio-facial disharmony that includes, but is not limited to:
An overjet greater than 9mm
A negative overjet greater than 3.5 mm
Posterior crossbite involving more than 4 teeth (combined between both arches)
Multiple missing permanent teeth
Impacted teeth

16. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Proposed medically necessary auto-qualifiers……… -These auto-qualifiers should have corroboration in research literature to be included in the assessment -Currently used by many states to determine Medicaid eligibility -???Other auto-qualifiers???: deep impinging OB with tissue trauma; anterior/posterior open bite; large A-P discrepancies

17. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Diagnostic Records needed to properly qualify a medically necessary orthodontic case are recommended as follows:
Intra and extra oral photographs
panoramic and cephalometric radiographs
diagnostic models - required only upon request by payers
Easy submission by providers and claims processing by payers.

18. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Summary Diagnosis should revolve around the severity of the malocclusion as a result of the cranio-facial disharmony. Automatic qualifiers (eventually becoming appropriate medical coding through ACA Essential Health Benefits) will allow insurance coverage of medically necessary orthodontic treatment as part of an overall corrective treatment plan involving other medical (or dental) specialists. Medically Necessary Orthodontics should be rendered only by a qualified orthodontic specialist.

19. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Summary
It is the hope of the AAO that treatment of medically necessary orthodontic cases be considered separate from what would be deemed routine orthodontic treatment, with different (and more stringent) requirements and coding (possibly under medical), as well as higher reimbursement levels from insurance companies. This would satisfy the ACA Essential Health Benefits without disrupting insurance approval of the estimated 95% of orthodontic cases nationwide.

20. Meeting with interested parties: -ADA- CDP, CDBP including CMC, CGA
Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
Suggested next steps:
Meeting with interested parties:
-ADA- CDP, CDBP including CMC, CGA
-CMS- Further definition of scope of coverage
-NADP- Use of coding, auto-qualifiers, and universally accepted diagnostic records. Higher reimbursement.
-AAO Cross agency support:
-COSA and Council on Education- corroboration of AQ and possible development of position paper a la AAPD
-COGA- support with CMS

21. Proposed Parameters for Insurance Approved Medically Necessary Orthodontic Treatment
QUESTIONS?