Medically Necessary Orthodontic Treatment – Dental ...

Medically Necessary Orthodontic Treatment Page 1 of 4 UnitedHealthcare Dental Coverage Guideline Effective 01/01/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. UnitedHealthcare Dental Cover a ge Guideline Medically Necessary Orthodontic Treatment Guideline Number: Effective Date: January 1, 2022 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Definitions .. 1 Applicable Codes .. 3 Description of Services .. 3 References .. 3 Guideline History/Revision Information .. 4 Instructions for Use .. 4 Coverage Rationale Orthodontic Treatment is Medically Necessary when the following criteria have been met: The member is under the age 19 (through age 18, unless the member specific benefit plan document indicates a different age); and Services are related to the Treatment of a severe craniofacial deformity that results in a physically Handicapping Malocclusion, including but not limited to the following conditions: o Cleft Lip and/or Cleft Palate; o Crouzon Syndrome/Craniofacial Dysostosis; o Hemifacial Hypertrophy/Congenital Hemifacial Hyperplasia; o Parry-Romberg S

Hematopoietic Cell Transplantation, and/or Radiation Therapy. Revised 2013. American Association of Orthodontists Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics 2014. American Association of Orthodontists Glossary 2017. Medically Necessary Orthodontic Treatment Page 4 of 4

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  Cells, Transplantation, Hematopoietic, Hematopoietic cell transplantation

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