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Medical Policy

Policy Num:      13.010.001
Policy Name:    Orthodontic Services
Policy ID:          [13.010.001]  [Ar / L / M+ / P+]  [0.00.00]

Last Review:      October 24, 2024
Next Review:      Policy Archived
 

Related Policies: None

Orthodontic Services

Summary

The branch of dentistry that is responsible for the study, prevention, diagnosis and treatment of anomalies in the shape, position, relationship and function of dentomaxillofacial structures.

Objective

Reestablish dentomaxillofacial relationship and function on patient with trauma, congenital anomalies or developmental and speech abnormalities that result in an unintelligible language.

Policy Statements

1. That sufficient functional disability be present as a result of disease, trauma, congenital anomalies or developmental dysfunction.  This functional disability must be directly related to a dent maxillofacial (maxilla and mandible) abnormality and must include one or more of the following:

     a. Significant intraoral trauma while chewing related to malocclusion. Information should be supplied which indicates the severity and duration of the trauma and the extent of the interruption to daily activities. This may include recurrent damage to the soft tissues of the mouth during mastication, lower incisors injuring the soft tissue of the palate, cheek biting, lip biting, impingement or irritation of buccal or lingual soft tissues of the opposing arch. The injury or damage to soft tissues must be documented by objective findings in the medical record and supported by photos.

    b. Speech abnormalities that result in an unintelligible language, which have not responded to speech therapy or frenulectomy.

    c. Documented loss of chewing or incisive function.

    d. Congenital condition where there are dentomaxillofacial deformities.

2. Significant over or underjet, documented by one of the following:

    a. A reverse overjet of 3mm or more, in cases of maxillary deficiency, or mandibular excess.

    b. An overjet of 4mm or more, in cases of mandibular deficiency.

    c. Open bite of 4mm or more.

    d. Deep bite of 7mm or more.

    e. Less than six (6) posterior teeth in functional opposition to other teeth as a result of abnormal growth or development (as opposed, to the result of tooth loss in the arch).

The following documents are required to consider the predeterminations of orthodontic services;

1. It must be accompanied with the completed form 193.

2. Lateral cephalometric radiography.

3. Tracing of the cephalometric with the corresponding measurements.

4. Photographs intra and extra oral pre-orthodontics.

5. Report that includes diagnosis (ICD-10) and corresponding CDT code.

6. Study model if necessary.

Policy Guidelines

All orthodontics treatment need:

·     Predetermination (radiographic imagines, medical condition report that included diagnosis (ICD-10) and corresponding CDT code., study model if necessary) and treatment plan and progress should be reported yearly.

·     Must be accompanied with the completed form 193.

a

Benefit Application

This policy is only applicable to Goverment Health Plan VITAL.  Applies only to the specialty of the Orthodontist.

Background

Misaligned teeth and an incorrect bite may affect more than just the appearance of your smile.  There are several types of malocclusion that can lead to more complex dental issues.

The initial consultation with the orthodontist is typically a visual evaluation of the patient’s teeth and facial structure. If the orthodontist requires more in-depth information, or the patient agrees to begin treatment, diagnostic records are then taken of the patient. These diagnostic tools, consisting of x-rays, models of the patient’s teeth, and photographs of the patient’s face and teeth, are used by the orthodontist to study and formulate a treatment plan to present to the patient. Although a referral from the PSP medical doctor is require.

Those who have more severe malocclusions, which present as a part of Craniofacial Anomalies, may require orthodontic and sometimes surgical treatment (orthognathic surgery) to correct the problem. Correction of malocclusion may reduce risk of tooth decay and help relieve excessive pressure on the temporomandibular joint.

The following conditions may potentially be corrected by orthodontics:

• Speech impediments
• Jaw or TMJ pain
• Difficulty chewing and eating
• Sleep apnea caused by mouth breathing and snoring
• Grinding or clenching of the teeth
• Dento alveolar deformities

Definitions of interest:

Open bite:

       Is a type of orthodontic malocclusion when there is no vertical overlap or contact between the anterior incisors or posteriors teeth.

 Types of open bites;  

·             Anterior open bite; Occurs when the front teeth fail to touch and there is no overlap between upper incisors and lower incisors. Anterior open can be caused by functional habits such as digit sucking, tongue thrust or long-term pacifier use.

·             Posterior open bite; Is caused when posterior teeth such as molars or premolars fail to touch their counterpart tooth

·             Skeletal open bite; Patient with skeletal open bites that accompany dental open bites may have Adenoid faces or Long face syndrome

·

Overbite:

       Overbite is a condition in which the upper front teeth overlap the lower front teeth

Cross bite:

       Is a form of malocclusion where a tooth (or teeth) has a more buccal or lingual position (that is, the tooth is either closer to the cheek or to the tongue) than its corresponding antagonist tooth in the upper or lower dental arch. In other words, cross bite is a lateral misalignment of the dental arches

Overjet:

       Is the extent of horizontal (anterior-posterior) overlap of the maxillary central incisors over the mandibular central incisors. In class II (division I) malocclusion the overjet is increased as the maxillary central incisors are protruded.

Reverse overjet (Uunderbite)

      Reverse overjet occurs when the lower jaw is ‘oversized’, or the upper jaw is undersized or a combination of both.  This usually results in the front teeth biting the wrong way around.  Reverse overjet can cause excessive wear to the surfaces of the incisor teeth and may be potentially damaging to growth and long-term function of the jaw joints. The jaw growth discrepancy often worsens in the late adolescence and definitive treatment for this problem is often deferred until growth has slowed or stopped. Excessive lower jaw growth is very commonly associated with facial asymmetry because the lower jaw tends to grow more on one side compared to the other.

Frenulectomy

        A Frenulectomy (also known as frenectomy or frenotomy) is the removal of a frenulum, a small fold of tissue that prevents an organ in the body from moving too far. It is related to frenuloplasty, a surgical alteration in a frenulum. Done mostly for orthodontic purposes, a frenectomy is either performed inside the middle of upper lip, which is called labial frenectomy, or under the tongue, called lingual frenectomy. Frenectomy is a very common dental procedure that is performed on infants, children, and adults. A similar procedure frenulotomy is where a tight frenulum may be relieved by making an incision in the tight tissue.

Regulatory Status

N/A

Rationale

To bring the patient by orthodontic treatment and in conjuction with surgery in other cases (Dento skeletal) to their best position whithin opposing teeth to correct bad bites. This will bring better masticatory function and speech giving more quality of life to patient with congenital deformities, abnormal growth of developmental teeth functional and traumas patients.

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American];LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflectiveof and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g.,women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Population Reference No. 1 

Individuals with congenital or developmental deformities affecting the dento maxillofacial structures.

Population Reference No. 2 

Individuals with significant values regarding; overjet, open bite, deep bite and abnormal growth or developmental teeth functional.

Population Reference No. 3 

Individuals with speech abnormalies resulting in an untelligible language

Population Reference No. 4 

Individuals with traumas affecting dentomaxillofacial function

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Coding Companion for Plastics, OMS and Dermatology, 2020.02.

2. CPT 2020 Surgical/Musculoskeletal System

3. Cain KK, Rugh JD, Hatch JP, Hurst CL. Readiness for orthognathic surgery: a survey of practitioner opinion. Int J Adult Orthodon Orthognath Surg 2002; 1 7(1):7-11
4. Kim JC, Mascarenhas AK, Joo BH et al. Cephalometric variables as predictors of Class II treatment outcome. Am J Orthod Dentofacial Orthop 2000;118(6):636-40
5. Mogavero FJ, Buschang PH, Wolford LM. Orthognathic surgery effects on maxillary growth in patients with vertical maxillary excess, Am J Orthod. Dentofacial Orthop 997;111(3):288‑96
6. Proffit WR, White RP Jr. Who needs surgical-orthodontic treatment? Int, J Adult Orthodon Orthognath Surg 1990;5(2):81‑9
7. Proffit WR, Phillips C, Tulloch JF et al. Surgical versus orthodontic correction of skeletal Class II malocclusion in adolescents: effects and indications Int, J Adult Orthodon Orthognath Surg 1992;7(4):209-20
8. Thomas PM. Orthodontic camouflage versus orthognathic surgery in the treatment of mandibular deficiency. J Oral Maxillofac. Surg. 1995;53(5):579-87
9. Wilmot JJ, Barber HD, Chou DG et al. Associations between severity of dentofacial deformity and motivation for orthodontic-orthognathic surgery treatment. Angle Orthod 1993;63(4):283-8
10. Wolford LM, Karras SC, Mehra P. Considerations for orthognathic surgery during growth, part 1: mandibular deformities. Am J Orthod Dentofacial Orthop 2001;119(2):95-101
11. Wolford LM, Karras SC, Mehra P. Considerations for orthognathic surgery during growth, part 2: maxillary deformities; Am J Orthod Dentofacial Orthop 2001; 119(2):102-5
12. Bill J, Proff P, Bayerlein T, Blens T, Gedrange T, Reuther J (September 2006). "Orthognathic surgery in cleft patients". J Craniomaxillofac Surg 34 (Suppl 2):77–81

13.  Uechi J, Okayama M, Shibata T, et al. (December 2006). "A novel method for the 3-dimensional simulation of orthognathic surgery by using a multimodal image-fusion technique". Am J Orthod Dentofacial Orthop 130 (6): 786–98. doi:10.1016/j.ajodo.2006.03.025. PMID 17169742.

14.  Orthodontic management of dentofacial skeletal deformities, John Grubb, DDS, MSD, Carla Evans, DDS, DMSC Clinics in plastic surgery, volume 34, issue 3, july 2007, pages 403-415

15.  Lainet T. Association between articulatory disorder in speech and occlusal anomalies. The European journal of orthodontics. 1987;9;144-150

16.  Jindra P, Spilden M, ber M, Pesak J. evaluation of speech disorders among childrens with osthodontic anomaly. Biomedical papers of the medical faculty of the University palacky, Olomouc, Czecholovakia, 2003;147:243-244

17.  Kindelan SA, Day PF, Kindela JD, ET AL. Dental Trauma; an overview of its influence on the management of orthodontic treatment: Part 1. Orthod 2008;35-68-78

18.  Chaushu S, Shapira J, Heling I, Becker A. Emergency Orthodonctic Treatment after the traumatic intrusive luxation of maxillary incisors. AM J Orthod Dentofacial Orthop 2004; 126:162-72

19.  Taylor KR, Kiyak A, Huang GJ, Greenlee GM, Jolley CJ, King GJ. Effects of Maloclusion and its treatment on the quality of life of adolecents. AM J. Orthod Dentofacial Orthop. 2009:136 (3):382-392

20.  Claudino D, Traebert J. Malocclusion, Dental Aesthetic Self-Prerception and quality of life INA 18 to 21 years-old populations: a cross section study. BMC Oral Health {Internet} 2013, 13:3 {Cited: 2014 Oct 22} Available from: http://www.bomedcentral.com/1472-6831/13/3

Codes

Appplicable Modifiers

N/A

Policy History